3-B TFI – Valid and trustful tilburg frailty index – Geriatric Nursing

Document ID *

Part a determinants of fragility

1. What is your gender? *

2. What is your age? *

3. What is your marital status? *

Other status

4. What is your country of birth? *

Other Country

5. What is the highest level of education you have completed? *

6. In which category does the net monthly income of your household? *

7. How healthy do you think everything is in your way of life? *

8. Do you have two or more diseases and / or chronic conditions? *

9. Did you have one or more of the following events experienced in the past year? *The death of a dear personA serious illness of your ownA serious illness of a loved oneA separation, breaking a sustainable, intimate relationshipA traffic accidentA crime

10. Are you satisfied with your living environment?

Part B Components of fragility, B1 Physical Components

11. Do you feel physically healthy? *

12. Have you lost a lot of weight lately without wanting this yourself? *

Do you have problems in everyday life due to

13. Walking badly? *

14. To be able to maintain yourself in balance poorly? *

15. Hearing badly? *

16. Seeing bad? *

17. Little power in your hands? *

18. Physical fatigue? *

B2 Psychological or cognitive components

19. Do you have complaints about your memory? *

20. Have you felt somber in the past month? *

21. Have you felt nervous or anxious during the past month? *

B3 Social components

22. Do you live alone? *

23. Do you ever miss people around you? *

24. Do you receive sufficient support from other people? *

Observations

Consent *

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