CUMULATIVE ILLNESS RATING SCALE (CIRS)

Similar documents
How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all

Premium Specialty: Pediatrics

J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health

Supplementary materials for:

Southwest Service Life Insurance Company

ANY FAMILY HISTORY OF ANEURYSM OR DVT?

In your own words, please write the reason you are here. Please be specific, putting in dates as necessary. Use the back of the form if needed.

EVIDENCE-BASED VITAMIN AND MINERAL USAGE SUMMARY TABLE (APRIL 2002)

Creighton University Internal Medicine Residency Curriculum Cycle of 33 months

UnitedHealth Premium Physician Designation Program Episode Treatment Groups (ETG ) Description and Specialty

LECOM Health Ophthalmology

MEDICAL HISTORY. Previous Nephrologist. Medication taken Insulin Oral Both. Who manages your diabetes? Blindness Yes No Hearing Problems Yes No

Internal Medicine End of Rotation

ICD-9-CM CODING FUNDAMENTALS CODING EXERCISES

Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1

Internal Medicine Certification Examination Blueprint

NurseAchieve. CHAPTERS INCLUDED IN THE NURSEACHIEVE COMPREHENSIVE NCLEX REVIEW NURSING SKILLS AND FUNDAMENTALS:

Episodes of Care Risk Adjustment

List of Qualifying Conditions

CHRONIC TREATMENT GUIDELINES

Pharmacotherapy Handbook

Table of Contents. Course CME Credits. General Principles Topic CME Credit(s)

Public Dissemination Effective: January 2018

DATE OF BIRTH: MELANOMA INTAKE

Evolve180 / Ideal Northwest Health Profile

PATIENT INFORMATION (Please print all information) Date:

RECOMMENDED COURSE ORDER

Patient Intake Form for Allegany Ear, Nose, & Throat

CENTRAL COAST ORTHOPEDIC MEDICAL GROUP Medical History Questionnaire GENERAL INFORMATION

Over. Signature of Patient/Parent/Guardian: Date: / / Date: / / Patient s Name: For ADULT Patients : Employer: Address: Occupation:

BOTLHE MEDICAL AID SCHEME - APPLICATION FORM

WASHINGTON UNIVERSITY SCHOOL OF MEDICINE. Cranial Health History Form

STEPHEN P. NONN OFFICE OF THE CORONER MADISON COUNTY, ILLINOIS 157 MAIN STREET SUITE 354 EDWARDSVILLE, IL

USMLE STEP 2 CK REVIEW STUDY GUIDE

PREAMBLE GENERAL DIAGNOSTIC RADIOLOGY

Barbara G. Wells, PharmD, FASHP, FCCP, BCPP Dean and Professor School of Pharmacy, The University of Mississippi Oxford, Mississippi

PLEASE COMPLETE ALL SECTIONS OF THIS FORM

Patient Information. Patient Name: DOB: Last First M.I. Home Address: City: State: Zip: Home Phn: Cell Phn: Alt. Phn: SSN:

[Supplementary online-only material for Fiest KM, Fisk JD, Patten SB, et al: Fatigue and

Phoenix Remembrance Life

CONTENTS 1. PUBLIC HEALTH ISSUES 2. SIGNS AND SYMPTOMS 3. DIAGNOSTIC TESTS 4. CARDIOVASCULAR DISEASES 5. RESPIRATORY DISEASES

Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:

SECTION I: ACTIVE DIAGNOSES. Active Diagnoses in the Last 7 Days

SUPPLEMENTARY MATERIAL

Medical Reference Library Table of Contents

Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain)

Notifiable Medical Conditions

MEDICAL HISTORY FORM FOR FOLLOW-UP

CONTENT OUTLINE FOR THE PHARMACOTHERAPY CERTIFICATION EXAMINATION

Table of Contents: 1. Neurology

Chapter 1 Certain Infectious and Parasitic Diseases

Measuring Long-Term Conditions in Scotland - A summary report

For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy. This form must be scanned into the medical record. Do not remove from clinic.

NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C.

THE RELATIONSHIP BETWEEN ACTIVITIES OF DAILY LIVING AND MULTIMORBIDITY. A VIEW FROM TELECARE

City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week

APR-DRG Description Ave Charge

Salt Lake Orthopaedic Clinic Initial Visit Form

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

S2 File. Clinical Classifications Software (CCS). The CCS is a

Ambulatory Rotation Mini-lecture Curriculum for IM Residents

MEDICAL HISTORY FORM FOR FOLLOW-UP

New Patient Paperwork

Welcome to Medina Family Chiropractic and Acupuncture!

Student Outline. Improving Transportation Safety: Commercial Driver Medical Examiner Training CHAPTER 1. General FMCSA Information

Detailed medical questionnaire Underwritten by Co-operators Life Insurance Company.

STEPHEN P. NONN OFFICE OF THE CORONER MADISON COUNTY, ILLINOIS 157 MAIN STREET SUITE 354 EDWARDSVILLE, IL

DRG Code DRG Description FY18 Average Charge

SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs. January 2018 WALK INS ARE ACCEPTED BUT WE ADVISE STUDENTS TO PRE-REGISTER BEFORE THURSDAY

Patient Interview Form

Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone

SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs. January 2019

Theses for the Final Exam of Pathology

New Patient Medical Questionnaire DATE:

Northwest Georgia Surgical Specialists, PC PAST MEDICAL HISTORY

Eligibility. Information about you. Information about your agent Only complete this section if you have an agent

Eligibility. Information about you. Information about your agent Only complete this section if you have an agent

Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone. Do you want statements ed? Y/N

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM

Chapter 32 Caring for the Elderly Client

SCHNEIDER MEDICAL GROUP, PA History Intake Form (Please Print)

Using 3-Digit ICD-9-CM Codes with the Elixhauser Comorbidity Index

Term & Universal Life Guidelines - Simplified

Pharmacy Prep. Qualifying Pharmacy Review

Course Name: Internal medicine course for 6 th year medical students

SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs. January 2018

Case Series Drug Analysis Print Name: Vaxigrip, Fluarix, Inflexal V og Influenzacvaccine 01Sep Oct2014

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

CHAPTERS OF ICD-10-CM

SHMI diagnoses July 2016 to June 2017

Lauren Griffith McMaster University

A Review of FDA PRO Labeling ( ) Ari Gnanasakthy RTI Health Solutions

FORESTERS: COLUMBIAN FINANCIAL GROUP: Smart U.L. Strong Foundation. Safe Shield. After 5 years, without relapse, no current use: ACCEPT

o Kidney Cancer o Liver Cancer o Tremor o Tuberculosis o B12 Deficiency o Esophageal Cancer o Liver Disease o Pituitary Tumor o Uterine o Neurological

HOME DIALYSIS Pre-Assessment Form

NC Neuropsychiatry, PA HEALTH QUESTIONNAIRE

PROPAEDEUTICS OF INTERNAL DISEASES EXAMINATION SYLLABUS. Part I - General

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

Patient Information. Insurance Information

Patient Health History

Transcription:

CUMULATIVE ILLNESS RATING SCALE (CIRS) The CIRS used in this protocol is designed to provide an assessment of recurrent or ongoing chronic comorbid conditions, classified by 14 organ systems. Using the lists of organ-specific diagnoses, please select any conditions present in the study subject. If the subject has a recurrent or ongoing chronic conditions that are not described in the list for a given organ system, please indicate the name of the conditions under other chronic condition for that organ system. Please take into account that CLL-induced discomfort, symptoms, or disability should not be considered. If additional explanation would be helpful, text comments may be inserted. For each condition selected from the CIRS List of Comorbid Conditions, please rate the severity of that condition. For the severity rating, please use the scoring guidelines shown in the table below, considering the magnitude of symptoms, how manageable the condition is, and the extent of intervention required. 1 2 3 4 Severity Mild Moderate Severe Extremely Findings Mild discomfort, symptoms or disability Easy to control Requiring either no therapy/medication or only as needed Moderate discomfort, symptoms or disability Manageable Requiring daily treatment or first-line therapy Severe discomfort, symptoms or disability Hard to control Requiring second-line therapy or multiple medications Life threatening, permanently disabling disability, causing organ failure Poorly manageable Requiring urgent intervention or resistant to therapy 1. Cardiac 2. Vascular Chronic heart failure Angina pectoris Medically relevant arrythmia Valve dysfunction Congenital heart disease Cardiomyopathy Myocarditis Chronic pericarditis Endocarditis Hypertension Thrombosis Peripheral diabetic microvascular disease Peripheral artery disease Aortic aneurysm Aortitis Raynaud disease Vasculitis Other: Version 1.0 1 of 5

3. Hematological/ immunological 4. Respiratory 5. Opthalmological/ otolaryngological Sickle cell anemia Hemoglobinopathy Polycythemia Thrombocythemia Hemophilia Paroxysmal nocturnal Thrombotic thrombocytopenic purpura Dysfibrinogenemia HIV Asthma Chronic obstructive pulmonary disease (COPD) Cystic Fibrosis Emphysema Chronic bronchitis Chronic pleural effusions Pulmonary fibrosis Sarcoidosis Pulmonary embolism Pulmonary arterial hypertension Lung cancer Other: Other: Loss of vision Glaucoma Cataract Macular degeneration Diabetic retinopathy Loss of hearing Otitis/chronic otitis Vestibular impairment Vertigo Temporomandibular disorder Sialolithiasis Chronic sinusitis Laryngeal/pharyngeal disorders Version 1.0 2 of 5

6. Upper GI 7. Lower GI 8. Hepatic/ pancreatic 9. Renal 10. Gynecological/ urological Chronic esophagitis Dysphagia Achalasia Gastroduodenal ulceration Celiac disease Irritable bowel syndrome Short bowel syndrome Malnutrition Malabsorption Small bowel obstruction Hernia Pseudomyxoma peritonei Upper gastrointestinal cancer Other: Other: Diverticulitis Inflammatory bowel disease Volvulus Colon cancer Other: Other: Chronic hepatitis or hepatic cirrhosis Biliary obstructive disorders Pancreatitis Hepatic, biliary, or pancreatic cancer Other: Other: Chronic kidney disease Diabetic nephropathy Pyelonephritis Renal cancer Other: Other: Recurrent/chronic urinary tract infection (UTI) Nephrolithiasis Bladder dysfunction Vaginal/vulvar disease Uterine/ovarian disease Prostatitis Bladder, uterine, ovarian, prostate, or other cancer Prostate hypertrophy Other: Other: Version 1.0 3 of 5

11. Dermatologic/ musculoskeletal 12. Neurological Dermatitis Dermatomyositis Myopathy Gout Psoriasis Keratosis Urticaria Scleroderma Basal cell carcinoma Squamous cell carcinoma Melanoma Osteomyelitis Osteoarthritis Rheumatoid arthritis Spondyloarthritis Temporal arteritis/polymyalgia rheumatica Polychondritis Fibromyalgia Osteoporosis Systemic lupus erythematosus Dermatomyositis Sjögren syndrome Other: Other: Cerebrovascular disease (transient ischemic attack (TIA)/stroke/hemorrhage) Dementia Parkinson disease Non-Parkinsonian movement disorder (eg, ataxia/chorea) Leukodystrophic disorders Amyotrophic lateral sclerosis Multiple sclerosis Demyelinating disease Guillain-Barré syndrome Paralysis (eg, para-/quadra- /hemiplegia) Myelopathy Cranial nerve disorder Degenerative disk disease with nerve root compression Migraine headaches Seizure disorder Secondary neuropathy (eg, diabetic/alcoholic/autoimmune) Neurofibromas/tuberous sclerosis Benign or malignant central nervous system tumor Other: Other: Version 1.0 4 of 5

13. Endocrine/ metabolic 14. Psychiatric Diabetes Adrenal disorder Thyroid disorder Parathyroid disorder Pheochromocytoma Pituitary disorder Hemochromatosis Porphyria Paget disease Endocrine or neuroendocrine tumor Other: Other: Depression Anxiety Bipolar disorder Paranoia Schizophrenia Neurosis Personality disorder Substance addiction/abuse Posttraumatic stress disorder Chronic fatigue syndrome Other: Other: Version 1.0 5 of 5

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback