Primary care tools for clinicians : a compendium of forms, questionnaires, and rating scales for everyday practice / by Lorraine Loretz
St. Louis, MO : Elsevier Mosby, c2005

Ref Desk RC65 .L67 2005
Media Center CDR-1580


PART ONE

DOCUMENTATION FORMS, LOGS, AND QUESTIONNAIRES

Comprehensive Adult History and Physical Form, 7, 11
Adult History and Physical Form - Female, 8, 15
Adult History and Physical Form - Male, 8, 17
Adult History and Physical – Female Short Form, 8, 19
Adult History and Physical - Male Short Form, 8, 20
Well-Woman History and Physical Exam, 9,21
Comprehensive Older Adult History and Physical Form, 9, 23
Office Visit Form, 9, 27
Medication History, 9, 28

Adult Health Profile, 32, 34
Adult Health Care Maintenance Record, 32, 35
Medication Log, 32, 36
Medication Refill Log, 32, 37
Injection Record, 32, 38
Adult Vaccine and PPD Administration Record, 32, 39
Pediatric Vaccine and PPD Administration Record, 32, 40
Laboratory Results, 33, 41
X-Ray and Special Procedure Results, 33, 42
Coagulation Monitoring Log, 33, 43
Blood Pressure Log, 33, 44
Vital Signs Flow Sheet, 33, 45
Diabetes Monitoring Log, 33, 46
Asthma Monitoring Log, 33, 47
Telephone Triage Call Record, 33, 48

Pediatric Initial Health Questionnaire, 50, 56
0 to 1-Month Well-Child Visit, 58
2-Month Well-Child Visit, 60
4-Month Well-Child Visit, 62
6-Month Well-Child Visit, 64
9-Month Well-Child Visit, 66
12 Month Well-Child Visit, 68
15-Month Well-Child Visit, 70
18-Month Well-Child Visit, 72
2-Year Well-Child Visit, 74
3-Year Well-Child Visit, 76
4-Year Well-Child Visit, 78
5-Year Well-Child Visit, 80
6 to 7-Year Well-Child Visit, 82
8 to 10-Year Well-Child Visit, 84
11 to 14-Year Well-Child Visit, 86
15 to 17-Year Well Visit, 88
18 to 20-Year Well Visit, 90
Well-Child Visit: Newborn to 4 Months, 92
Well-Child Visit: 6 to 12 Months, 93
Well-Child Visit: 15 Months to 2 Years, 94
Well-Child Visit: 3 to 5 Years, 95
Well-Child Visit: 6 to 11 Years, 96
Well-Adolescent Visit: 12 to 18 Years, 97
Screening Form for Early Follow-up of Breastfed Infants, 52, 98
Breastfeeding Infant Triage Form, 52, 99
Periodic Blood Lead Screening Risk Questionnaire, 52, 100
Tuberculosis Risk Questionnaire, 52, 101
Adolescent Risk Monitoring Log, 53, 102
Adolescent Questionnaire (GAPS), 53, 103

Preparticipation Physical Evaluation Form, 106, 111
Preparticipation Physical Evaluation Clearance Form, 108, 113
Medical Conditions and Sports Participation, 108, 114
Classification of Sports by Contact, 108, 106
Patient-Runner History Form, 108, 117

Mental Health Assessment Form, 122, 129
Child Psychiatry Emergency Consultation Mental Status Examination Checklist, 122, 132
Substance Use History and Physical Examination Form, 122, 135
Abuse Assessment Screen, 123, 139
Partner Violence Screen, 123
Spouse Abuse: Assessing Level of Violence in the Home, 123, 124
SAFE Technique, 124
RADAR Screening Tool,124
SIG E CAPS, 125
SALSA, 125
BATHE, 125,126
HOPE, 126
SPIRIT, 127
ETHNIC, 127, 128

Level I Nutrition Screen, 142, 145
Level II Nutrition Screen, 142, 146
Determine Your Nutritional Health, 142, 147
Medications Use Checklist, 142, 148
Nutrition History, 142, 149
General Food Frequency Questionnaire, 142, 150
Food Intake Record, 142, 152
Nutrition History Form (ADA), 142, 152
Initial Nutrition Assessment Form, 142, 153
Food Diary, 142, 154
A One-Day (24 Hour) Record of Food Intake, 142, 155
Perinatal Nutrition Screening/Assessment Form, 143, 158
Eating Disorder Nutritional Assessment Form, 143, 159
Herbal, Botanical, and Dietary Supplement Intake Form, 143, 160

Stepwise Approach to Preoperative Cardiac Assessments, 165, 172
American Society of Anesthesiologists Physical Status Classification System, 167
Preoperative Clearance Evaluation Form: Adult, 167, 173
Preoperative Clearance Evaluation Form: Pediatric, 167, 175
Medical Examination Report for Commercial Driver Fitness Determination (649-F [6045]), 168, 177
Physical Qualifications for Drivers (49 CFR 391.41), 168, 180
Instructions to the Medical Examiner: Federal Motor Carrier Safety Regulations-Advisory Criteria, 168, 181
Medical Examiner's Certificate (650-FS-L2 [6046]), 168, 185
Medical Examination of Aliens Seeking Adjustment of Status (1-693), 170, 186
Medical Clearance Requirements for Aliens Seeking Adjustment of Status, 170, 189

PART TWO

MEASUREMENT TOOLS AND RATING SCALES

Maturational Assessment of Gestational Age (New Ballard Score), 197, 210
Centers for Disease Control and Prevention 2000 Growth Charts for the United States, 197
Boys 0-36 Months: Length for Age/Weight for Age, 211
Boys 0-36 Months: Head Circumference for Age/Weight for Length, 212
Girls 0-36 Months: Length for Age/Weight for Age, 213
Girls 0-36 Months: Head Circumference for Age/Weight for Length, 214
Boys 2-20 Years: Stature for Age/Weight for Age, 215
Boys 2-20 Years: Body Mass Index for Age, 216
Boys 2-20 Years: Weight for Stature, 217
Girls 2-20 Years: Stature for Age/Weight for Age, 218
Girls 2-20 Years: Body Mass Index for Age, 219
Girls 2-20 Years: Weight for Stature, 220
Growth Charts for Children with Down Syndrome, 198
Weight: Birth-3 Years, Girls, 221
Weight: 2-18 Years, Girls, 222
Weight: Birth-3 Years, Boys, 223
Weight: 2-18 Years, Boys, 224
Length: Birth-3 Years, Girls, 225
Height: 2-18 Years, Girls, 226
Length: Birth-3 Years, Boys, 227
Height: 2-18 Years, Boys, 228
Head Circumference: Birth-3Years, Girls, 229
Head Circumference: Birth-3 Years, Boys, 230
Tanner Stages of Development, 199, 231
Apgar Newborn Scoring System, 199, 232
Baby Check Scoring System, 199, 233
The Injury Behavior Checklist, 200, 234
CHAT (Checklist for Autism in Toddlers), 205, 235

Global Assessment of Functioning Scale (GAF)/Global Assessment Scale (GAS), 239, 263
Problem Oriented Screening Instrument for Teenagers (POSIT), 240, 264
Center for Epidemiologic Studies-Depression (CES-D) Scale, 242, 269
Center for Epidemiologic Studies-Depression Scale for Children (CES-DC), 242
Hamilton Rating Scale for Depression (HRSD), 242, 270
Montgomery Asberg Depression Rating Scale (MADRS), 243,271
Primary Care Evaluation of Mental Disorders: Patient Health Questionnaire 9-Item Depression Module (PRIME-MD PHQ-9), 244, 273
Zung Self-Rating Depression Scale (SDS), 244, 274
Edinburgh Postnatal Depression Scale (EPDS), 245, 275
Geriatric Depression Scale (GDS), 245, 276
Cornell Scale for Depression in Dementia (CSDP), 246, 277
Hamilton Anxiety Rating Scale (HARS), 248, 278
Zung Self-Rating Anxiety Scale (SAS), 249,279
Yale-Brown Obsessive Compulsive Scale (Y BOCS), 249,280
Y BOCS Symptom Checklist, 281
Florida Obsessive-Compulsive Inventory (FOCI), 249, 282
Liebowitz Social Anxiety Scale (LSAS), 250, 284
Recent Life Changes Questionnaire (RLCQ), 250, 285
Overt Aggression Scale-Modified (OAS-M), 252,288
Rating Scale for Aggressive Behavior in the Elderly (RAGE), 253, 291
HITS-Safety Questionnaire, 253, 292
Modified SAD PERSONS Scale, 254, 293
4-Item Risk of Suicide Questionnaire (RSQ-4), 254, 294
CAGE Questionnaire, 256, 295
T -ACE Questionnaire, 256, 296
Michigan Alcoholism Screening Test (MAST), 257, 297
Alcohol Use Disorders Identification Test (AUDIT), 257, 298
Drug Abuse Screening Test (DAST), 258, 299
CRAFFT, 259, 300
SCOFF Questionnaire, 260, 301
Eating Disorder Screen for Primary Care (ESP), 260, 302
Eating Attitudes Test (EAT 26), 260, 303

Instrumental Activities of Daily Living Scale (IADL), 306, 317
Structured Assessment of Independent Living Skills (SAILS), 307, 318
Five-Item Instrumental Activities of Daily Living Screening (Brief IADL), 307, 320
Hearing Handicap Inventory for the Elderly-Screening (HHIE-S) Version, 307, 321
Tinetti Balance and Gait Evaluation/ Performance-Oriented Assessment of Mobility, 309, 322
Risk Assessment Tool (RAT) for Falls, 310, 324
Reassessment is Safe "Kare" (RISK) Tool, 310, 325
Guidelines for Home Safety Assessment, 310, 326
Environmental Assessment for the Elderly, 310, 327
Driving Skills Quiz, 310, 328
Brief Abuse Screen for the Elderly (BASE), 310, 329
Caregiver Abuse Screen (CASE), 311, 330
Blessed Dementia Scale and Information¬Memory-Concentration (IMC) Test, 311, 331
FROMAJE Mental Status Guide, 312, 332
Set Test, 312
6-Item Cognitive Impairment Test (6CIT), 314, 334
Hachinski Ischemic Score (HIS) for Multi-Infarct Dementia, 315, 335

Spitzer's Quality of Life (QL) Index, 338, 347
COOP Functional Assessment Charts, 339, 348
The Duke Health Profile, 339, 351
Arthritis Impact Measurement Scale-2 (AIMS2), 353-360
Barthel Index, 342, 361
Katz Activities of Daily Living, 343, 362
Functional Status Index (FSI), 343, 364
Functional Independence Measure (FIMTM), 344, 365
Pain Disability Index (PDI), 345, 367

Verbal Descriptor Scale (VDS), 372, 382
Numeric Rating Scale (NRS), 372, 382
Visual Analogue Scales (VAS), 378, 382
Wong/Baker Faces Rating Scale, 378, 383
Oucher Scales, 378, 384
Faces Pain Scale-Revised (FPS-R), 378, 385
Brief Pain Inventory (BPI)-Short Form, 379,388
Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), 380, 390
Neonatal Infant Pain Scale (NIPS), 380, 391
Body Outline Tool, 381, 392
Geriatric Pain Assessment Form, 381, 393

National Pressure Ulcer Advisory Panel (NPUAP) Staging System for Pressure Ulcerations, 396, 399
Wagner Wound Classification, 396, 399
University of Texas Diabetic Wound Classification System, 397, 400
Norton Pressure Ulcer Prediction Scale, 397, 401
Braden Scale for Predicting Pressure Sore Risk, 398, 402

Body-Mass Index (BMI), 403, 406
Height and Weight Assessment, 403, 407
Mini Nutritional Assessment (MNA), 403, 408
USDA Food Guide Pyramid, 404, 409
Food Guide Pyramid for Young Children, 404, 410
Willett's Healthy Eating Pyramid, 404, 411
Food Guide Pyramid for Vegetarian Meal Planning, 404, 412

New York Heart Association (NYHA) Classification for Congestive Heart Failure (CHF), 414, 415
FACES Screening Tool for Heart Failure, 416
Revised Cardiac Risk Index, 416, 417
Rosenbaum Chart, 418, 428
Amsler Grid, 419, 429
Self-Assessment Hearing Test, 419, 430
Burke Dysphagia Screening Test (BDST), 419
Epworth Sleepiness Scale (ESS), 420, 431
Glasgow Coma Scale, 420, 421
Modified Glasgow Coma Scale, 421
Headache Diary, 422, 432
Berg Balance Scale, 423, 433
Abnormal Involuntary Movement Scale (AIMS), 423,435
Rhodes Index of Nausea and Vomiting-Revised (INVR), 424, 436
Constipation Assessment Scale (CAS), 425, 437
Androgen Deficiency in Aging Males (ADAM) Questionnaire, 425, 438
Brief Male Sexual Function Inventory for Urology, 429, 439
Incontinence Impact Questionnaire (IIQ-7) and Urogenital Distress Inventory (UDI-6), 426, 440

The Family APGAR, 442, 448
Zarit Burden Interview (ZBI), 443, 449
Support for Caregivers Questionnaire, 443, 450
Duke UNC Functional Social Support (DUFSS), 444, 451
Lubben Social Network Scale (LSNS), 444, 452
UCLA Loneliness Scale, 444, 453
Jarel Spiritual Well-Being, 445, 454
Survey of Pain Attitudes (SOPA), 445, 455