CFS Tree - Full

For each question, please check the box that best describes your patient's usual health state. If they are currently ill, think about their health state approximately two weeks ago.

1) Is your patient terminally ill?

Yes

2) Could your patient...

	Yes, without help from another person	No, unable to do OR can only do with help from another person
dress and undress themself (including putting on socks and shoes)?
eat?
walk?
get in and out of bed?
take a bath or shower?

3) Could your patient...

	Yes, without help from another person	No, unable to do OR can only do with help from another person	Never had to do before OR always relied on someone else
use the telephone (including looking up numbers and dialing)?
go shopping for groceries or clothes?
prepare their own meals (including planning and cooking full meals)?
do their housework (including heavy housework)?
take their own medicine (including preparing it and taking the right dose at the right time)?
handle their own money (including writing cheques and paying bills)?

4) Has a doctor ever told your patient that they have or had any of the following health conditions which are expected to last, or have already lasted, 6 months or more?

	Yes	No
Emphysema, chronic bronchitis, chronic obstructive pulmonary disease (COPD), or chronic changes in lungs due to smoking
High blood pressure or hypertension
Diabetes, borderline diabetes, or high blood sugar
Heart disease (including congestive heart failure or CHF)
Angina (or chest pain due to heart disease), heart attack, or myocardial infarction
Cancer
Memory problem
Dementia or Alzheimer’s disease
Osteoarthritis in the knee, hip or hands
Rheumatoid or other type of arthritis
Peripheral vascular disease or poor circulation in your limbs

	Yes	No
Stroke or CVA (cerebrovascular accident)
Mini-stroke or TIA (Transient Ischemic Attack)
Parkinsonism or Parkinson’s disease
Intestinal or stomach ulcers
Bowel disorder such as Crohn’s Disease, ulcerative colitis, or Irritable Bowel Syndrome
Glaucoma
Macular degeneration
Osteoporosis, sometimes called low bone mineral density, or thin, brittle, or weak bones
Back problems, excluding fibromyalgia and arthritis
Underactive thyroid gland (sometimes called hypothyroidism or myxedema) or overactive thyroid gland (sometimes called hyperthyroidism or Graves’ disease)
Kidney disease or kidney failure

Does your patient any other chronic health conditions?

Yes

Please record the number of other chronic health conditions:

5) Would your patient say that their health, in general is/was:

Excellent

Very Good

Good

Fair

Poor

6) In a typical week, how often does your patient feel that everything they do is/was an effort?

Rarely or never (Less than 1 day)

Some of the time (1 to 2 days)

Occasionally (3 to 4 days)

All of the time (5 to 7 days)

7) In a typical week, how often does/did your patient engage in moderate or strenuous sports or recreational activities (such as dancing, golf without a cart, softball, jogging, swimming, cycling, or other similar activities)?

Never

Seldom (1 to 2 days)

Sometimes (3 to 4 days)

Often (5 to 7 days)

Please click 'View Results' to see the Clinical Frailty Scale score. Your data will not be saved once you exit the page.

Based on the responses from the questionnaire, the Clinical Frailty Scale score is:

Terminally Ill

Approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise living with severe frailty. Many terminally ill people can still exercise until very close to death.

Living With Very Severe Frailty

Completely dependent for personal care and approaching end of life. Typically, they could not recover even from a minor illness.

Living With Severe Frailty

Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within ~ 6 months).

Living With Moderate Frailty

People who need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.

Living With Mild Frailty

People who often have more evident slowing, and need help with high order instrumental activities of daily living (finances, transportation, heavy housework). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation, medications and begins to restrict light housework.

Living With Very Mild Frailty

Previously “vulnerable,” this category marks early transition from complete independence. While not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed up” and/or being tired during the day.

Managing Well

People whose medical problems are well controlled, even if occasionally symptomatic, but often not regularly active beyond routine walking.

Fit

People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g., seasonally.

Very Fit

People who are robust, active, energetic and motivated. They tend to exercise regularly and are among the fittest for their age.

Do you agree with this Clinical Frailty Scale score?

Yes

What Clinical Frailty Scale score would you assign? (Use the tool below to view all categories)

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Thank you for completing the Clinical Frailty Scale classification tool. If you wish to use it again, please refresh the page.

For more information about the Clinical Frailty Scale , please visit the website below:

Geriatric Medicine Research website

You may return to the questionnaire and modify your answers or print these results:

Please use the slider to view descriptions for each category of the Clinical Frailty Scale.