Resources for the Comprehensive Geriatric Assessment based

Proactive and Personalised Primary Care of the Elderly

Brief CGA Template

Purpose : Data collection for Initial abbreviated Comprehensive Geriatric Assessment

Admin time : x min. variable

User Friendly : High

Administered by : GP or nurse

Content : Selected CGA data

Author : Lyndon H and Stevens G, 2014

Ref. : Toolkit for general practice in supporting older people with frailty and achieving the requirements of the unplanned
admissions enhanced service (2014)

Copyright : Public domain

https://www.cgakit.com/brief-cga-template
 Brief Comprehensive Geriatric Assessment

Patient Contact Clinical Frailty Score (Rockwood Scale):

Home
Care Home Patient's Details Patient's Address
GP Title Add 1
OPD Name Add 2
ED Date of Birth Add 3
NHS Number Town
Frailty
GP Practice Postcode

Cognition Within Normal Limits Mild Cognitive Impairment Dementia Delerium

Abbreviated Mental test (AMT) Score: Mental Capacity Assessment required
Main lifelong occupation:
Emotional Within Normal Limits ↓Mood Depression Anxiety Fatigue Hallucination
Delusion Other
Motivation High Usual Low
Health Attitude Excellent Good Fair Poor Couldn't say
Communication Speech: Within Normal Limits Impaired Hearing: Within Normal Limits Impaired
Vision: Within Normal Limits Impaired Understanding: Within Normal Limits Impaired
Strength Within Normal Limits Weak Upper: Proximal Distal Lower: Proximal Distal
Exercise Frequent Occasional Not
Balance Balance Within Normal Limits Impaired Within Normal Limits Impaired
Falls Falls Number: Falls Number:
Mobility Walk inside Independent Slow Assisted Can't Independent Slow Assisted Can't
Walk outside Independent Slow Assisted Dependent Independent Slow Assisted Dependent
Transfers Independent Standby Assisted Dependent Independent Standby Assisted Dependent
Bed (in/out) Independent Pull Assisted Dependent Independent Pull Assisted Dependent
Aid use
None Stick Frame Chair None Stick Frame Chair
Nutrition Weight Normal Under Over Obese Normal Under Over Obese
Appetite Within Normal Limits Fair Poor Within Normal Limits Fair Poor
Swallow Within Normal Limits Impaired Fluids Within Normal Limits Impaired Fluids
Baseline (two weeks ago)

Impaired Solids Impaired Solids

Current (today)

Elimination Bowel Continent Constipated Incontinent Continent Constipated Incontinent

Bladder Continent Catheter Incontinent Continent Catheter Incontinent
ADLS Feeding Independent Assisted Dependent Independent Assisted Dependent
Bathing Independent Assisted Dependent Independent Assisted Dependent
Dressing Independent Assisted Dependent Independent Assisted Dependent
Toileting Independent Assisted Dependent Independent Assisted Dependent
IADLS Cooking Independent Assisted Dependent Independent Assisted Dependent
Cleaning Independent Assisted Dependent Independent Assisted Dependent
Shopping Independent Assisted Dependent Independent Assisted Dependent
Medications Independent Assisted Dependent Independent Assisted Dependent
Driving Independent Assisted Dependent Independent Assisted Dependent
Banking Independent Assisted Dependent Independent Assisted Dependent
Sleep Disrupted Daytime drowsiness Socially Engaged Frequent Occasional Not
Marital Status Lives Home Supports
Social Married Alone House… Number of levels: Informal
Divorced Spouse Steps… Number of steps: Other
Widowed Other Apartment Requires more support
Single Supported Living None
Care Home
Other Caregiver Relationship Caregiver Stress
Spouse None
Sibling Low
Offspring Moderate
Advance directive in place: Yes No Other High
CPR decision: Allow a natural death Resuscitate Caregiver Occupation:

Assessor:
(Name, Grade & Signature)
Date:
PLEASE TURN
Initial Comprehensive Geriatric Assessment Form

Associated Medication *(Mark meds started in hospital with an asterisk) - Consider STOPP / START
Medication Dose Date Commenced

Problem List Action Required Action by:

1
2
3
4
5
6
7
8
9
10
Long Term Conditions:
1
2
3
4
5
Notes:

For MDT discussion, consider long CGA Long CGA not required, copy of Clinical Frailty score to GP

Outpatient Appointments
Department Date and Time

Assessor:
(Name, Grade & Signature)
Date:

Helen Lyndon and Dr Grant Stevens : Toolkit for general practice in supporting older people with frailty and achieving the requirements of the Unplanned Admissions Enhanced Service (2014)