MDVIP Health Assessment (Male)

Duke Activity Status Index

Patient's Name

Date

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.

1. Can you take care of yourself (eating, dressing, bathing or using the toilet)?

Yes (2.75) No (0)

2. Can you walk indoors such as around your house?

Yes (1.75) No (0)

3. Can you walk a block or two on level ground?

Yes (2.75) No (0)

4. Can you climb a flight of stairs or walk up a hill?

Yes (5.50) No (0)

5. Can you run a short distance?

Yes (8.00) No (0)

6. Can you do light work around the house like dusting or washing dishes?

Yes (2.70) No (0)

7. Can you do moderate work around the house like vacuuming, sweeping floors or carrying in groceries?

Yes (3.50) No (0)

8. Can you do heavy work around the house like scrubbing floors or lifting and moving heavy furniture?

Yes (8.00) No (0)

9. Can you do yard work like raking leaves, weeding or pushing a power mower?

Yes (4.50) No (0)

10. Can you have sexual relations?

Yes (5.25) No (0)

11. Can you participate in moderate recreational activities like golf, bowling, dancing, doubles tennis or throwing a baseball or football?

Yes (6.00) No (0)

12. Can you participate in strenuous sports like swimming, singles tennis, football, basketball or skiing?

Yes (7.50) No (0)

Duke Activity Status Index

Estimated peak oxygen uptake in mL/min

Interpretation:

maximum value 58.2
minimum value 0

The Burns Depression Checklist

Patient's Name

Date

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.

1. Sadness: Have you been feeling sad or down in the dumps?

0 - Never 1- Somewhat 2 - Moderately 3 - A lot

2. Discouragement: Does the future look hopeless?

0 - Never 1- Somewhat 2 - Moderately 3 - A lot

3. Low self-esteem: Do you feel worthless or think of yourself as a failure?

0 - Never 1- Somewhat 2 - Moderately 3 - A lot

4. Inferiority: Do you feel inadequate or inferior to others?

0 - Never 1- Somewhat 2 - Moderately 3 - A lot

5. Guilt: Do you get self-critical and blame yourself for everything?

0 - Never 1- Somewhat 2 - Moderately 3 - A lot

6. Indecisiveness: Do you have trouble making your mind up about things?

0 - Never 1- Somewhat 2 - Moderately 3 - A lot

7. Irritability and frustration: Have you been feeling resentful and angry a good deal of the time?

0 - Never 1- Somewhat 2 - Moderately 3 - A lot

8. Loss of interest in life: Have you lost interest in your career, your hobbies, your family, or your friends?

0 - Never 1- Somewhat 2 - Moderately 3 - A lot

9. Loss of motivation: Do you feel overwhelmed and have to push yourself hard to do things?

0 - Never 1- Somewhat 2 - Moderately 3 - A lot

10. Poor self-image: Do you think you're looking old or unattractive?

0 - Never 1- Somewhat 2 - Moderately 3 - A lot

11. Appetite changes: Have you lost your appetite, or do you overeat or binge compulsively?

0 - Never 1- Somewhat 2 - Moderately 3 - A lot

12. Sleep changes: Do you suffer from insomnia and find it hard to get a good night's sleep? Or are you excessively tired and sleeping too much?

0 - Never 1- Somewhat 2 - Moderately 3 - A lot

13. Loss of libido: Have you lost your interest in sex?

0 - Never 1- Somewhat 2 - Moderately 3 - A lot

14. Hypochondriasis: Do you worry a great deal about your health?

0 - Never 1- Somewhat 2 - Moderately 3 - A lot

15. Suicidal impulses: Do you have thoughts that life is not worth living or think that you might be better off dead?

0 - Never 1- Somewhat 2 - Moderately 3 - A lot

Add your total score for the 15 symptoms and record it here

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

Patient's Name

Date

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

Usually eat: less than 4 servings of grain products a day

Usually eat: 4-5 servings of grain products a day

Usually eat: 6 or more servings of grain products a day

2. WHOLE GRAINS

Usually eat: white breads, white rice, low fiber cereals like corn flakes, rice krispies, etc.

Sometimes eat: less than 4 servings of grain products a day

Usually eat: whole grain breads, brown rice, whole grain cereals like oatmeal, bran cereals, Wheaties™, etc.

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

Usually eat: 1 serving or less a day

Usually eat: 2-4 servings a day

Usually eat: 5 or more servings a day

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

Rarely eat or drink: 2 or more servings of milk, yogurt, or cheese a day

Sometimes eat or drink: 2 or more servings of milk, yogurt, or cheese a day

Usually eat or drink: 2 or more servings of milk, yogurt, or cheese a day

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

Usually eat: more than 6 ounces of meat, chicken, turkey or fish per day

Sometimes eat: more than 6 ounces of meat, chicken, turkey or fish per day

Rarely/never eat: more than 6 ounces of meat, chicken, turkey or fish per day

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

Usually eat out or get take-out food: twice a week or more

Usually eat out or get take-out food: once a week or more

Usually eat out or get take-out food: less than once a week OR usually eat low-fat restaurant meals

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

Usually eat: three times a week or more

Usually eat: twice a week

Usually eat: once a week or less

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

Usually eat: high-fat cuts, such as ribs, brisket, T-bone steak, prime rib, sausage, regular or lean ground beef

Sometimes eat: high-fat cuts, such as ribs, brisket, T-bone steak, prime rib, sausage, regular or lean ground beef

Usually eat: lean beef such as round, loin, flank, lean pork and lamb such as loin and leg, veal, ground turkey breast OR rarely/never eat meat

9. COLD CUTS, HOT DOGS, BREAKFAST MEATS

Usually eat: salami, bologna, other cold cuts, hot dogs, bacon, sausage

Sometimes eat: salami, bologna, other cold cuts, hot dogs, bacon, sausage

Usually eat: roast beef, turkey breast, ham or low-fat cold cuts, low-fat hot dogs, low-fat bacon/sausage

10. CHICKEN, TURKEY, ETC.

Usually eat: chicken, turkey, and other poultry with skin

Sometimes eat: chicken, turkey, and other poultry with skin

Usually eat: chicken, turkey, and other poultry without skin

11. CHICKEN AND FISH CHOICES

Usually eat: fried chicken and/or fried fish and shellfish

Sometimes eat: fried chicken and/or fried fish and shellfish

Usually eat: chicken and fish that is baked, broiled, grilled, poached, roasted, etc.

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

Rarely eat: meatless main dishes

Usually eat: meatless main dishes less than twice a week

Usually eat: meatless main dishes twice a week or more

13. MILK

Usually eat: whole milk or cream

Usually eat: 2% reduced-fat milk

Usually eat: 1% low-fat or skim milk

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

Usually eat: regular cheese such as cheddar, Swiss and American

Sometimes eat: regular cheese such as cheddar, Swiss and American

Usually eat: reduced-fat or part-skim cheese OR rarely eat cheese

15. FROZEN DESSERTS
Ice cream, etc.

Usually eat: regular ice cream, ice cream bars/sandwiches

Sometimes eat: regular ice cream, ice cream bars/sandwiches

Usually eat: sherbet, sorbet, low-fat frozen yogurt or ice cream OR rarely eat frozen desserts

16. COOKING METHOD

Usually add: oil, butter or margarine to the pan

Sometimes add: oil, butter or margarine to the pan

Usually eat: broil, bake or steam without fats or oils or use cooking sprays (Pam)

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

Usually eat: fried foods

Sometimes eat: fried foods

Rarely/Never eat: fried foods

18. SPREADS
added at the table

Usually put: butter or stick margarine on bread, potatoes, vegetables, etc.

Usually put: liquid or tub margarine on bread, potatoes, vegetables, etc.

Usually put: "light" tub margarine on bread, potatoes, vegetables. etc. OR eat them plain

19. SALAD DRESSING & MAYONNAISE

Usually use: regular salad dressing or mayonnaise

Sometimes use: regular salad dressing or mayonnaise

Usually use: light or fat-free salad dressing and mayonnaise

20. SNACKS

Usually eat: regular chips, crackers, and nuts

Sometimes eat: regular chips, crackers, and nuts

Usually eat: fruits, pretzels, low-fat crackers or baked chips

21. DESSERTS AND SWEETS

Usually eat: donuts, cookies, cake, pie, pastry or chocolate

Sometimes eat: donuts, cookies, cake, pie, pastry or chocolate

Usually eat: fruit, angel food cake, low-fat or fat-free sweets

22. ADDED SALT

Usually: add salt to food when cooking or at the table

Sometimes: add salt to food when cooking or at the table

Never: add salt to food when cooking or at the table

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

Often eat: salty snacks

Sometimes eat: salty snacks

Rarely/Never eat: salty snacks

24. CANNED FOODS, FROZEN PACKAGED MEALS

Usually: choose regular/canned/frozen packaged foods

Sometimes: choose regular/canned/frozen packaged foods

Usually: choose low-sodium canned/frozen/packaged foods OR rarely eat these foods

25. DESSETS AND SWEETS

Usually eat: high sugar desserts and sweets

Sometimes eat: high sugar desserts and sweets

Usually eat: low sugar desserts and sweets

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

Usually drink: 16 oz. or more of regular (non-diet) soda, punch, etc. per day

Usually drink: 8-15 oz. or more of regular (non-diet) soda, punch, etc. per day

Usually drink: less than 8 oz. or more of regular (non-diet) soda, punch, etc. per day

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

Often drink: more than 1-2 alcoholic drinks in a day

Sometimes drink: more than 1-2 alcoholic drinks in a day

Rarely/Never drink: more than 1-2 alcoholic drinks in a day

FIND YOUR RATE YOUR PLATE SCORE

Total check in column A

X 1

Score

Total check in column B

X 2

Score

Total check in column C

X 3

Score

TOTAL

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

Patient's Name

Date

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?

Yes

No

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?

Yes

No

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

Yes

No

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

Yes

No

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

Epworth Sleepiness Scale

Patient's Name

Date

Physician Name: Deirdre McMullen, M.D.

Your age

Gender

Male Female

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 and 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

Sitting and reading

0 1 2 3

Watching TV

0 1 2 3

Sitting, inactive in a public place (e.g. theatre or a meeting)

0 1 2 3

A passenger in a car for an hour without break

0 1 2 3

Lying down to rest in the afternoon when circumstances permit

0 1 2 3

Sitting and talking to someone

0 1 2 3

Sitting quietly after a lunch without alcohol

0 1 2 3

In a car, while stopped for a few minutes in traffic

0 1 2 3

TOTAL

Score:

0-10 Normal range

10-12 Borderline

12-24 Abnormal

Beck Anxiety Index

Patient's Name

Date

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.

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.)

Numbness or tingling

0 1 2 3

Feeling hot

0 1 2 3

Wobbliness in legs

0 1 2 3

Unable to relax

0 1 2 3

Fear of the worst happening

0 1 2 3

Dizzy or lightheaded

0 1 2 3

Heart pounding or racing

0 1 2 3

Unsteady

0 1 2 3

Terrified

0 1 2 3

Nervous

0 1 2 3

Feelings of choking

0 1 2 3

Hands trembling

0 1 2 3

Shaky

0 1 2 3

Fear of losing control

0 1 2 3

Difficulty breathing

0 1 2 3

Fear of dying

0 1 2 3

Scared

0 1 2 3

Indigestion or discomfort in abdomen

0 1 2 3

Faint

0 1 2 3

Face flushed

0 1 2 3

Sweating (not due to heat)

0 1 2 3

TOTAL

Maximum score = 63 points

0-7 Minimal Anxiety

8-15 Mild Anxiety

16-26 Moderate Anxiety

26-63 Severe Anxiety

SAFE Questions

Patient's Name

Date

Physician Name: Deirdre McMullen, M.D.

Do you feel safe in your relationship?

Have you ever been in a relationship where you were threatened, hurt or afraid?

Are your friends or family aware that you have been hurt? Could you tell them, and they would be able to give you support?

Do you have a safe place to go and the resources you need in an emergency?

Sexual Health Inventory for Men (SHIM)

Patient's Name

Date

Physician Name: Deirdre McMullen, M.D.

PATIENT INSTRUCTIONS

Sexual health is an important part of an individual's overall physical and emotional well-being. Erectile dysfunction, also known as impotence, is one type of very common medical condition affecting sexual health. Fortunately, there are many different treatment options for erectile dysfunction. This questionnaire is designed to help you and your doctor identify if you may be experiencing erectile dysfunction. If you are, you may choose to discuss treatment options with your doctor.

Each question has possible several responses. Click the number of the response that best describes your own situation. Please be sure that you select one and only one response for each question.

OVER THE PAST SIX MONTHS

1. How would you rate your confidence that you could get and keep an erection?

Very Low (1) Low (2) Moderate (3) High (4) Very High (5)

2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?

No sexual activity - 0 Almost Never or Never - 1 A Few Times (much less than half the time) - 2 Sometimes (about half the time) - 3 Most Times (much more than half the time) - 4 Almost Always or Always - 5

3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?

Did Not Attempt Intercourse - 0 Almost Never or Never - 1 A Few Times (much less than half the time) - 2 Sometimes (about half the time) - 3 Most Times (much more than half the time) - 4 Almost Always or Always - 5

4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

Did Not Attempt Intercourse - 0 Extremely Difficult - 1 Very Difficult - 2 Difficult - 3 Slight Difficult - 4 Not Difficult - 5

5. When you attempted sexual intercourse, how often was it satisfactory for you?

Did Not Attempt Intercourse - 0 Almost Never or Never - 1 A Few Times (much less than half the time) - 2 Sometimes (about half the time) - 3 Most Times (much more than half the time) - 4 Almost Always or Always - 5

Add the numbers corresponding to questions 1-5. TOTAL

The Sexual Health Inventory for Men further classifies ED severity with the following breakpoints:

1-7 Severe ED

8-11 Moderate ED

12-16 Mild to Moderate ED

17-21 Mild ED

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