Examining Physician

EXAMINING PHYSICIAN

/ or identifying stamp
Last name:
First name:
Center:

Year ______

Last name of patient: ______

First name of patient:______

SOCIAL DATA

Professional situation

1- / Profession: / ______
2- / If active
a) / Full time...... / 
Part time...... / 
b) / General area...... / 
Specialized area...... / 
3- / If inactive / Date: ______
______
a) / Due to illness...... / 
b) / Not due to illness...... / 

Source of income

1- / None (Welfare)...... / 
2- / Social security, retirement...... / 
3- / Unemployment insurance...... / 
4- / Other (specify).... / ______
Lifestyle(at home)
1- / Lives alone / 
2- / Family / 
3- / In an institution / 

Housing

1- / Adapted / 
2- / Partially adapted / 
3- / Non adapted / 

Technical assistance

1- / No assistance / 
2- / Assistance when in movement
1) / Manual wheelchair / 
2) / Electric wheelchair / 
3) / Electric wheelchair with vertical lift / 
4) / Pushchair / 
5) / Scooter / 
3- / Assistance with communication
1) / Computer(to write/communicate) / 
2) / Adapted communication system
(example: vocal synthesizer) / 
4- / Assistance in hygiene
1) / Adapted toilets / 
2) / Adapted bathroom / 
5- / Assistance for transportation
1) / Adapted transportation / 
2) / Adapted vehicle / 
6- / Human assistance
1) / None / 
2) / Home care for essential, every day living, for example: hygiene, eating , dressing) / 
3) / Assistance in social situations(activities, errands) / 

SUPERIOR FUNCTIONING

Education

1- / Primary / 
2- / Secondary / 
3- / College / 
4- / University / 
5- / Age when studies ended
Education/Age:
Personality disorder / yes /  / no / 
Behavioural problems / yes /  / no / 
1- / Diabetes (glycaemia >7.1 mmol/L)
...... / yes /  / no / 
Insulin therapy...... / yes /  / no / 
Oral hypoglycaemic agents ...... / yes /  / no / 
2- / Thyroid pathology...... / yes /  / no / 
Type: …………………………………………
3- / Other (Specify): …………………………………

OBSTETRICAL ASSESSMENT

1- / Pregnancies total......
2- / FCS (before 22 WA), total......
3- / Fœtal death (after 22 WA), total......
4- / Neonatal death (before D29), total......
5- / Definite sterilization...... / yes /  / no / 
6- / Sterility (failed to become pregnant for 18 month period) / yes /  / no / 
Diurnal drowsiness / Yes  / No 
Epworth Scale
Never / Rarely / Sometimes / Frequently
While sitting down reading / 0 / 1 / 2 / 3
While watching television / 0 / 1 / 2 / 3
While seated in a public place / 0 / 1 / 2 / 3
Passenger in a car for over an hour non-stop / 0 / 1 / 2 / 3
When lying down at lunch time / 0 / 1 / 2 / 3
Seated and speaking with someone / 0 / 1 / 2 / 3
Seated after a meal (without alcohol consumption) / 0 / 1 / 2 / 3
In a car stopped in traffic / 0 / 1 / 2 / 3
EDS Score (0-24):
DSS Scale
Never / Rarely / Often / Always
Do you take one or several naps during the
day? / 0 / 1 / 2 / 3
Do you feel an overwhelming and sudden need to sleep during the day? / 0 / 1 / 2 / 3
Do you fall asleep while watching television or at the movies? / 0 / 1 / 2 / 3
Do you have difficulty remaining inactive for long periods of time during the day? / 0 / 1 / 2 / 3
Do you usually feel well during the day? / 3 / 2 / 1 / 0
DSS Score (0-15):

Motor - MRC

/

Right

/

Left

· /

Neck flexors

· / Shoulder abductors
· / Elbow flexors
· / Elbow extendors
· / Wrist extendors
· / Finger flexors
· / Hip flexors
· / Knee extendors
· / Knee flexors
· / Posterior foot flexors
· / Plantar flexors

MRC Score:

Functional testing

· / Dynamometrics( 2 JAMAR dynamometrics measurements on average) (kg)
Right hand ______
Left hand ______
· / Handicap scale:
Normal...... / 0
Walking, running, normal jumps, some cramps and fatigue...... / 1
Normal walking, running, jumping impossible...... / 2
Abnormal walking but without assistance...... / 3
Abnormal walking with simple cane...... / 4
Abnormal walking with English cane...... / 5
Abnormal walking with walker...... / 6
Wheelchair...... / 7
Bedridden...... / 8
Score (0-8):
· / Time needed to walk 10 m (sec): / ______
With walker, cane...... / 
With human assistance...... / 
Impossible...... / 
· / Myotonia (delay in muscle relaxation)
Absent / 0
Electrical/Percussion only / 1
Gripping ability: moderate / 2
Gripping ability: severe / 3
Muscular Disability Rating Scale (MDRS)

No clinical signs. Diagnosis by EMG or DNA analysis......

/ 1
Myotonia, weakness in the face, neck, palpebral ptosis, nasal voice, no distal weakness except for finger flexors / 2

Distal weakness without proximal weakness except for triceps......

/ 3

Moderate proximal weakness......

/ 4
Severe proximal weakness (wheelchair needed)...... / 5

BILAN CARDIAQUE

Year of examination: / ______
Examiner______
Normal cardiac assessment? /  / yes
Pace-maker (year it was put in) / ______
Defibrillator(year it was put in) / ______
ECG
Rhythm:

• оо

/ Normal...... / 0
ESA or ESV 2...... / 1
ESA or ESV 2...... / 2
FA or Flutter...... / 3
TV...... / 4
Rhythm score ( /4)
Auricular conduction

• о

/ Normal...... / 0
BAV 1...... / 1
BAV 2...... / 2
BAV 3...... / 3
Other...... / 
Conduction score ( /3)
Ventricular conduction
Normal / 0
BB incomplete...... / 1
Bibloc (BBD + hemiBBG)..... / 2
BB complete...... / 3
Other...... / 
Conduction score ( /3)

RESPIRATORY ASSESSMENT

Year of examination: / ______

Normal respiratory assessment?

/  / yes

Assisted breathing

No...... / 0
Upon effort...... / 1
At night...... / 2
Permanent...... / 3
Invasive (tracheotomy).. / 4
Vital capacity (% predicted value)
/ Sitting down
/ Lying down
Blood gas
/ PaO2 (mm Hg)
/ PaCO2 (mm Hg)
/ Saturation (%)

Respiratory handicap scale

CV  75%...... / 1
40% ≤CV < 75%...... / 2
CV < 40%...... / 3

DIGESTIVE ASSESSMENT

Normal digestive assessment? yes
Gastrostomia / yes / Year: ______
Cholecystectomia / yes / Year: ______
Coughing while eating or drinking:
0 Never or < 2/mos
1 > 2/mos
2 > 1/week
Time required to swallow 80 CCs of water: sec Chocking: yes no
(cone shaped plastic cup)
Anal/urinary incontinence / no /  / yes / 
Height(m) ______
Weight loss in the past year (related to the disease):  5% / no /  / yes / 
Current weight (kg) ______
Last year’s weight (kg)______

Loss(kg) ______

Loss (%)______

Digestive handicap scale

No problems...... / 0
Coughing when eating or drinking more than twice/month and swallowing time >6 sec and ≤ 18 sec., no weight loss
………………………………………………………………………………………………………………. / 1
Coughing when eating or drinking more than once/week and/or swallowing time >18 sec., choking on water and/or weight loss / 2
Gastrostomia...... / 3
Score:

OPHTALMOLOGICAL ASSESSMENT

Year of examination: / ______
Cataract(posterior with coloured opaqueness)
Absent...... 0
Present and visible via ophthalmoscope...... 1
Operated on...... 2
Year of first operation: / ______
Associated hereditary disease: ______
Consultations and hospitalizations: (over the course of the previous year)
Number of consultations and/or hospitalizations / ______
Number of consultations and/or hospitalizations (in relation with the disease) / ______
Therapeutic protocols:
1- / Previous inclusion: / yes /  / no /  / Year of last protocol / ______
2- /

Refusal

/ 
(Revised December 2, 2008) / 1