Fitness Assessment for Patients ≥70 years old in Breast Clinic

Does the patient already have a known diagnosis of dementia?

Yes (omit AMTS assessment)

No (complete all the assessments)

Clinical Frailty Scale

Please enter a number from 0 to 10.

Please insert appropriate number

Abbreviated Mental Test Score

Ask the following questions to the patient. Each question that is correctly answered scores one point:

1. What is your age?

2. What is the time to the nearest hour?

3. Give the patient an address, ask him/her to repeat it at the end of the test e.g. 42, West Street

4. What is the year?

5. What is the name of the hospital/ number of residence where the patient is situated?

6. Can the patient recognise two persons (e.g. the □ doctor, nurse etc.)?

7. What is your date of birth? (day and month □ sufficient)

8. In what year did World War 1 begin?

9. Name the present monarch/prime minister

10. Count backwards from 20 to 1

Patient chose not to answer al questions

Total Score

Please enter a number from 0 to 10.

Does the patient have any other non-breast locally advanced / metastatic malignancy?

Yes

Does the patient have severe* cardiorespiratory disease?

* severe = less than ordinary physical activity or rest causes tiredness, palpitations or shortness of breath

Yes

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