MDVIP Health Assessment (Female)

Please correct the errors described below.

Duke Activity Status Index

Physician Name: Deirdre McMullen, M.D.


Overview:

The Duke Activity Status Index is a self-administered questionnaire that measures a patient's functional capacity. It can be used to get a rough estimate of a patient's peak oxygen uptake.

Interpretation:

  • maximum value 58.2
  • minimum value 0

The Burns Depression Checklist

Physician Name: Deirdre McMullen, M.D.

Instructions: The following is a list of symptoms that people frequently have. Select the option that best describes how much that symptom or problem has bothered you during the past week.

It will be between 0 (if you have answered "not at all" for each of the 15 categories) and 45 (if you have answered "a lot" for each one). Use the key to interpret the score.

Total scores and degrees of depression

  • 0 - 4 Minimal or no depression
  • 5 - 10 Borderline depression
  • 11 - 20 Mild depression
  • 21 - 30 Moderate depression
  • 31 - 45 Severe depression

Rate Your Plate

Physician Name: Deirdre McMullen, M.D.


Think about the way you usually eat. For each food topic, put a check mark in column A, B, or C.

TOPIC

A

B

C

1. GRAINS
1 Serving = 1 slice bread or tortilla; 1/2 bagel, roll, English muffin or pita; 1/2 cup cooked rice or pasta; 1 cup cereal

2. WHOLE GRAINS

3. FRUITS & VEGETABLES
1 Serving = 1/2 cup cooked or 1 med. fruit or 1 cup leafy raw vegetables or 4 oz. 100% fruit or veg. juice

4. DAIRY FOODS
1 Serving = 1 cup milk or yogurt; 1 1/2 - 2 ounces cheese

5. MEAT, CHICKEN, TURKEY OR FISH
1 Serving = 3 oz. (the size of a deck of cards) or 1 regular hamburger, 1 chicken breast or leg, or 1 pork chop

6. EATING OUT
in restaurants or getting take-out food

7. RED MEAT
(includes beef, hamburger, pork, lamb or veal)

8. RED MEAT CHOICES
(includes beef, hamburger, pork, lamb or veal)

9. COLD CUTS, HOT DOGS, BREAKFAST MEATS

10. CHICKEN, TURKEY, ETC.

11. CHICKEN AND FISH CHOICES

12. MEATLESS MAIN DISHES
such as all-bean chili, bean burrito, lentil soup, meatless spaghetti sauce

13. MILK

14. CHEESE
includes cheese on pizza, sandwiches, snacks and mixed dishes

15. FROZEN DESSERTS
Ice cream, etc.

16. COOKING METHOD

17. FRIED FOODS
such as french fries, egg rolls, onion rings, etc.

18. SPREADS
added at the table

19. SALAD DRESSING & MAYONNAISE

20. SNACKS

21. DESSERTS AND SWEETS

22. ADDED SALT

23. SALTY SNACKS
chips, pretzels, crackers, salted nuts

24. CANNED FOODS, FROZEN PACKAGED MEALS

25. DESSETS AND SWEETS

26. SODA, PUNCH, ETC
Soda, pop, fruit drink, punch, Kool-Aid™, etc.

27. BEER, WINE, LIQUOR
1 Drink = 12 oz. beer, 5 oz. wine, one shot of hard liquor or mixed drink with 1 shot

FIND YOUR RATE YOUR PLATE SCORE


X 1


X 2


X 3

If your score is:

27-45: There are many ways you can make your eating habits healthier.

46-63: There are some ways you can make your eating habits healthier.

64-81: You are making many healthy choices.

The CAGE and CAGE-AID Questionnaires

Physician Name: Deirdre McMullen, M.D.

The original CAGE questions appear in a plain type. The CAGE questions Adapted to Include Drugs (CAGE-AID) are the original CAGE questions modified by the italicized text.

The CAGE or CAGE-AID should be preceded by these two questions:

1. Do you drink alcohol?

2. Have you ever experimented with drugs?

If the patient has experimented with drugs, ask the CAGE-AID questions. If the patient only drinks alcohol, ask the CAGE questions.

CAGE and CAGE-AID Questions

1. In the last three months, have you felt you should cut down or stop drinking or using drugs?

2. In the last three months, has anyone annoyed you or gotten on your nerves by telling you to cut down or stop drinking or using drugs?

3. In the last three months, have you ever felt guilty or bad about how much you drink or use drugs?

4. In the last three months, have you been waking up wanting to have an alcoholic drink or use drugs?


Each affirmative response earns one point. One point indicates a possible problem. Two points indicate a probable problem.

Epworth Sleepiness Scale

Physician Name: Deirdre McMullen, M.D.

How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired?

This refers to your usual way of life in recent times.

Even if you haven't done some of these things recently try to work out how they would have affected you.

Use the following scale to choose the most appropriate number for each situation:

0 = Would never doze

1 = Slight chance of dozing

2 = Moderate chance of dozing

3 = High chance of dozing

Situations

Score:

0-10 Normal range

10-12 Borderline

12-24 Abnormal

Beck Anxiety Index

Physician Name: Deirdre McMullen, M.D.

Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by each symptom during the PAST WEEK, INCLUDING TODAY, by selecting the corresponding option for each symptom.

Use the following scale to choose the most appropriate number for each symptom.

Score:

0 = Not at all

1 = Mildly (It did not bother me much.)

2 = Moderately (It was very unpleasant, but I can stand it.)

3 = Severely (I could barely stand it.)

Maximum score = 63 points

0-7 Minimal Anxiety

8-15 Mild Anxiety

16-26 Moderate Anxiety

26-63 Severe Anxiety

SAFE Questions

Physician Name: Deirdre McMullen, M.D.

Klemes Female Sexual Function Screener

Physician Name: Deirdre McMullen, M.D.

INSTRUCTIONS: These questions ask about your present experience. Your responses will be kept completely confidential.

CHECK ONLY ONE BOX PER QUESTION


Scoring:

a. 0 points

b. 1 point

c. 2 points

d. 3 points


Total:

0-3: No action

4-10: Assess further

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