346 (346)    MH REPORT (601.93)

|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.>)