Protocol rv 254, search 010

4
Karnofsky

100 = Normal

090 = Able to carry on normal activity; minor signs or

symptoms of disease.

080 = Normal activity with effort; some signs or symptoms

of disease.

070 = Cares for self, unable to carry on normal activity or to

do active work

060 = Requires occasional assistance but is able to care for

most needs.

050 = Requires considerable assistance and frequent medical

care.

040 = Disabled, requires special care and assistance.

030 = Severely disabled, hospitalization is indicated

although death is not imminent.

020 = Very sick, hospitalization necessary; active support

treatment is necessary.

010 = Moribund, fatal processes progressing rapidly.

000 = Dead
7b. Results of exam exclusive of neuropathy

01 Done, abnormal (not to include neuropathy). Specify:

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

8. 
   Exam not done. Specify why: _______________
   

00 All items completed

01 Partially completed, most items done

02 Unable to test most items, subject agitated

03 Unable to test most items, other reason:

__________________________________________

Abridged Neuropsychological Assessment Test Battery

Non-dominant Hand Number of Drops _________________

Error: _______________

1. 
   Color Trails 1 and 2
   

00 Reliable, standardized test administration

01 Questionable test results (specify reason)

02 Invalid test results (specify reason)

Examiner Comments and Observations:_____________________________________________




2. Grooved Pegboard
00 Reliable, standardized test administration

01 Questionable test results (specify reason)

02 Invalid test results (specify reason)

Examiner Comments and Observations:_____________________________________________

01 Questionable test results (specify reason)

02 Invalid test results (specify reason)

Examiner Comments and Observations:________________________________________

1. Most of the time

2. A lot of the time

3. From time to time, occasionally

4. Not at all
2. I still enjoy the things I used to enjoy.

1. Definitely as much

2. Not quite as much

3. Only a little

4. Hardly at all
3. I get a sort of frightened feeling as if something awful is about to happen.

1. Very definitely and quite badly

2. Yes, but not too badly

3. A little, but it doesn't worry me

4. Not at all
4. I can laugh and see the funny side of things.

1. As much as I always could

2. Not quite so much now

3. Definitely not so much now

4. Not at all

5. Worrying thoughts go through my mind.

1. A great deal of the time

2. A lot of the time

3. From time to time but not too often

4. Only occasionally
6. I feel cheerful.

1. Not at all

2. Not often

3. Sometimes

4. Most of the time

7. I can sit at ease and feel relaxed.

1. Definitely

2. Usually

3. Not often

4. Not at all
8. I feel as if I am slowed down.

1. Nearly all the time

2. Very often

3. Sometimes

4. Not at all
9. I get a sort of frightened feeling like "butterflies" in the stomach.

1. Not at all

2. Occasionally

3. Quite often

4. Very often
10. I have lost interest in my appearance.

1. Definitely

2. I don't take so much care as I should

3. I may not take quite as much care

4. I take just as much care as ever
11. I feel restless as if I have to be on the move.

1. Very much indeed

2. Quite a lot

3. Not very much

4. Not at all
12. I look forward with enjoyment to things.

1. As much as I ever did

2. Rather less than I used to

3. Definitely less than I used to

4. Hardly at all
13. I get sudden feelings of panic.

1. Very often indeed

2. Quite often

3. Not very often

4. Not at all
14. I can enjoy a good book or radio or TV program.

1. Often

3. Not often

4. Very seldom

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)
Over the last 2 weeks, how often have you been bothered by any of the following problems?

(Please uses “X” to indicate your answer)

	Not at all	Several days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself—or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual.
9. Thoughts that you would be better off dead or of hurting yourself in some way.
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