CLINICAL FRAILTY SCALE

Date: [Date]
Patient: [Name or ID, age]
Setting: [Emergency department, admission, preoperative clinic, geriatric clinic, or home visit]
Scored by: [Name, credentials]
Form: [Official CFS version 2.0]

BASELINE
Reference point: [Usual state about 2 weeks before the acute illness began, or current usual state if not unwell]
Information from: [Patient, family member, carer, care home staff, or records; name and relationship]

LEVEL
CFS level: [1 to 9, with its name on the official scale]
Group: [Not frail, very mild frailty, mild to moderate frailty, or severe frailty to terminally ill]
How the person appears today: [Same as baseline, or worse because of the acute illness, and how]

REASONS FOR THE LEVEL
Daily activities: [Household tasks, shopping, money, medicines, transport; bathing, dressing, toileting; what is done alone, with help, or by others]
Mobility: [Walking aid, distance, stairs, rising from a chair, falls in the past year, time in bed or chair]
Cognition: [Memory concerns, dementia diagnosis and stage, delirium now]
Health conditions: [Main conditions, how well symptoms are controlled, number of regular medicines]
Activity and self-rated health: [Exercise or daily activity, and how the person rates their health against others their age]

USE IN THE PLAN
Purpose: [Prognosis, goals-of-care conversation, surgical risk, discharge planning, or referral]
What it informed: [Decisions made, alongside the acute illness, treatment options, and the wishes of the person]
Discussed with: [Patient, family or named decision-maker, team members]
Rescore: [After recovery, before discharge, or at the next review]

Clinician: [Name, credentials]