EDMONTON FRAIL SCALE

Date: [Date]
Patient: [Name or ID, age]
Setting: [Preoperative clinic, primary care, geriatric clinic, hospital consult, or home visit]
Given by: [Name, role]
Form and language: [Official bedside EFS under a University of Alberta license; translation if used]
Why now: [Planned surgery, cancer treatment decision, new falls or weight loss, annual check-up, or referral]

DOMAIN POINTS
Cognition, clock drawing: [Points; errors seen]
General health: [Points; hospital stays in the past year and self-rated health]
Functional independence: [Points; daily tasks that need help]
Social support: [Points; who helps when needed]
Medication use: [Points; number of regular medicines and any missed doses]
Nutrition: [Points; recent weight loss]
Mood: [Points; what the person reported]
Continence: [Points; type of leakage, or none]
Functional performance, timed up and go: [Points; seconds and walking aid, or why it wasn't done]

TOTAL
EFS total: [0 to 17]
Band: [Not frail, vulnerable, mild frailty, moderate frailty, or severe frailty]
Earlier totals: [Dates and totals, or first score]

DOMAINS DRIVING THE SCORE
Contributing domains: [Each domain that scored, most concerning first]
Checked further: [Delirium, memory testing, depression screen, standing blood pressure, weight trend, labs]

CARE PLAN BY DOMAIN
Falls and mobility: [Fall risk assessment, physical therapy, walking aid, home safety, or not needed]
Medicines review: [Medicines stopped, reduced, or changed; pharmacist review; blister pack]
Nutrition: [Dietitian, supplements, dental or swallowing review, next weight check]
Social support: [Home care, caregiver support, social worker, community programs]
Mood and memory: [Screening done, treatment, referral, or follow-up]
Continence: [Causes looked for, treatment, products, or referral]
Goals of care: [What matters most to the person, decisions it informed, named decision-maker]
Before surgery or treatment: [Prehabilitation, geriatric co-management, delirium prevention, timing, or not applicable]

FOLLOW-UP
Rescore EFS: [Date or trigger]
Shared with: [Patient, family, surgeon, family doctor, home care team]

Clinician: [Name, credentials]