| RPT |
|ALS Functional Rating Scale - Revised (ALSFRS-R)
| Gender: <.Patient_Gender.>
|
| ALSFRS-R Total Score = <-Total->
| Scores range from 0 to 48, with higher scores indicating that more
| function is retained.
|
|Questions and Answers:
|
| 1. Speech
| <*Answer_9515*>
|
| 2. Salivation
<*Answer_7771*>
| 3. Swallowing
| <*Answer_9517*>
| 4. Handwriting
| <*Answer_9518*>
| 5. Does Veteran have a gastrostomy
| <*Answer_9519*>
| 5A. Cutting food and handling utensils (patients without gastrostomy)
| <*Answer_9520*>
| Date Given: <.Date_Given.>
| 5B. Cutting food and handling utensils (patients with gastrostomy)
| <*Answer_9521*>
| 6. Dressing and hygiene
<*Answer_7772*>
| 7. Turning in bed and adjusting bed clothes
| <*Answer_9523*>
| 8. Walking
| <*Answer_9524*>
| 9. Climbing stairs
| <*Answer_9525*>
| Clinician: <.Staff_Ordered_By.>
| 10. Dyspnea
<*Answer_7773*>
| 11. Orthopnea
<*Answer_7774*>
| 12. Respiratory insufficiency
| <*Answer_9528*>
|
|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
| Location: <.Location.>
|other diagnostic activities.
|
| Veteran: <.Patient_Name_Last_First.>
| SSN: <.Patient_SSN.>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
