| RPT |
|Medical Research Council Breathlessness Scale (MRC)
| Gender: <.Patient_Gender.>
|
| MRC Grade <-Total->
|
|
|Questions and Answers:
|
| 1. Are you ever troubled by breathlessness except on strenuous
| exertion?
| <*Answer_8974*>
|
| 2. Are you short of breath when hurrying on the level or walking up
| a slight hill?
| <*Answer_8975*>
| 3. Do you have to walk slower than most people on the level? -or-
| Do you have to stop after a mile or so (or after 1/4 hour) on the
| level at your own pace?
| <*Answer_8976*>
| 4. Do you have to stop for breath after walking about 100 yds. (or
| after a few minutes) on the level?
| <*Answer_8977*>
| Date Given: <.Date_Given.>
| 5. Are you too breathless to leave the house, or breathless after
| undressing?
| <*Answer_8978*>
|
|Information contained in this note is based on a self-report assessment
|and is not sufficient to use alone for diagnostic purposes. Assessment
|results should be verified for accuracy and used in conjunction with
|other diagnostic activities.
| Clinician: <.Staff_Ordered_By.>
| Location: <.Location.>
|
| Veteran: <.Patient_Name_Last_First.>
| SSN: <.Patient_SSN.>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
