پرسشنامه ها

برای دریافت پرسشنامه های ارزیابی توانبخشی به سایت زیر مراجعه نمایید

http://www.rehabmeasures.org/rehabweb/allmeasures.aspx?PageView=Shared

NIH Stroke Scale/Score (NIHSS)

۱A: Level of Consciousness
(If intubated/difficult to assess, make best guess, but only choose ۳ if posturing/unresponsive)
Alert; keenly responsive ۰
Not Alert, but arousable by minor stimulation ۱
Not Alert, requires repeated stimulation to arouse ۲
Not Alert/Obtunded, Makes Movements to Pain ۲
Postures or Unresponsive to Pain ۳
۱B: Ask Month and Age Both Questions Right ۰
Answers ۱ Question Right ۱
Answers ۰ Questions Right ۲
Dysarthric, Intubated, Trauma, Language Barrier ۱
Aphasic ۲
۱C: Tell Patient To Open and Close Eyes, then Hand Grip Squeeze
(Substitute/Pantomime Commands if Language Barrier/Confusion)
Performs Both Tasks Correctly ۰
Performs One Task Correctly ۱
Performs ۰ Tasks Correctly ۲
۲: Test Horizontal Extraocular Movements Normal Extraocular Movements ۰
Partial Gaze Palsy: Can Be Overcome ۱
Partial Gaze Palsy: Corrects with Oculocephalic Reflex ۱
Forced Gaze Palsy: Cannot Be Overcome ۲
۳: Test Visual Fields No Visual Loss ۰
Partial Hemianopia ۱
Complete Hemianopia ۲
Patient is Bilaterally Blind ۳
Bilateral Hemianopia ۳
۴: Test Facial Palsy
(Use Grimace if Obtunded)
Normal symmetrical movements ۰
Minor paralysis (flat nasolabial fold, smile asymetry) ۱
Partial paralysis (total/near-total lower face paralysis) ۲
Unilateral Complete paralysis (no facial movement upper/lower face) ۳
Bilateral Complete paralysis (no facial movement upper/lower face) ۳
۵A: Test Left Arm Motor Drift No Drift for ۱۰ Seconds ۰
Drift, but does not hit bed/support ۱
Drift, but hits bed/support ۲
Some Anti-Gravity Effort ۲
No Effort Against Gravity ۳
No Movement ۴
Amputation/Joint Fusion Unable
۵B: Test Right Arm Motor Drift No Drift for ۱۰ Seconds ۰
Drift, but does not hit bed/support ۱
Drift, but hits bed/support ۲
Some Anti-Gravity Effort ۲
No Effort Against Gravity ۳
No Movement ۴
Amputation/Joint Fusion Unable
۶A: Test Left Leg Motor Drift No Drift for ۵ Seconds ۰
Drift, but does not hit bed ۱
Drift, but hits bed/support ۲
Some Anti-Gravity Effort ۲
No Effort Against Gravity ۳
No Movement ۴
Amputation/Joint Fusion Unable
۶B: Test Right Leg Motor Drift No Drift for ۵ Seconds ۰
Drift, but does not hit bed ۱
Drift, but hits bed/support ۲
Some Anti-Gravity Effort ۲
No Effort Against Gravity ۳
No Movement ۴
Amputation/Joint Fusion Unable
۷: Test Limb Ataxia
(FNF/Heel-Shin)
No Ataxia ۰
Ataxia in ۱ Limb ۱
Ataxia in ۲ Limbs ۲
Does Not Understand ۰
Paralyzed ۰
Amputation/Joint Fusion Unable
۸: Test Sensation Normal; No sensory loss ۰
Mild-Moderate Loss: Less Sharp/More Dull ۱
Mild-Moderate Loss: Can Sense Being Touched ۱
Complete Loss: Cannot Sense Being Touched At All ۲
No Response and Quadriplegic ۲
Coma/Unresponsive ۲
۹: Test Language/Aphasia
(Describe the scene; name the words; read the sentences.)

Normal; No aphasia ۰
Mild-Moderate Aphasia: Some Obvious Changes, Without Significant Limitation ۱
Severe Aphasia: Fragmentary Expression, Inference Needed, Cannot Identify Materials ۲
Mute/Global Aphasia: No Usable Speech/Auditory Comprehension ۳
Coma/Unresponsive ۳
۱۰: Test Dysarthria
(Read the words.)
Normal ۰
Mild-Moderate Dysarthria: Slurring but can be understood ۱
Severe Dysarthria: Unintelligble Slurring or Out of Proportion to Dysphasia ۲
Mute/Anarthric ۲
Intubated/Unable to Test UN
۱۱: Test Extinction/Inattention No abnormailty ۰
Visual/tactile/auditory/spatial/personal inattention ۱
Extinction to bilateral simultaneous stimulation ۱
Profound hemi-inattention (ex: does not recognize own hand) ۲
Extinction to >۱ modality ۲
NIH Stroke Scale:
Remember, an NIH Stroke Scale of ۰ does not mean the patient is not having a stroke! (Notorious for missing posterior circulation strokes.)

Bottom of Form

 

Barthel Index

Patient Name:  __________________   Rater: ____________________  Date:      /     /              :      

  References: Mahoney Fl, Barthel DW:Functional evaluation: the Barthel Index. Md State Med J ۱۴:۲, ۱۹۶۵. van der Putten JJMF, Hobart JC; Freeman JA, Thompson AJ. (۱۹۹۹) Measuring the change indisability after inpatient rehabilitation; comparison of the responsiveness of the Barthel Index and Functional Independence Measure. Journal of Neurology, Neurosurgery, and Psychiatry, ۶۶(۴), ۴۸۰-۴۸۴. PubMed Link to abstract 

Items: The FIM consists of ۱۸ items assessing ۶ areas of function. The items fall into two domains: Motor (۱۳ items) and Cognitive (۵ items). The motor items are based on the items of the Barthel Index. These domains are referred to as the Motor-FIM and the Cognitive-FIM.The items of the FIM are listed as follows:Motor Domain: ۱. Self-care (۶ items) ·         Eating·         Grooming·         Bathing ·         Dressing-upper body·         Dressing-lower body·         Toileting۲. Sphincter control (۲ items) ·         Bladder management·         Bowel management۳. Transfers (۳ items)·         Bed/chair/wheelchair·         Toilet·         Tub/shower۴. Locomotion (۲ items) ·         Walk/wheelchair·         StairsCognitive Domain: ۵. Communication (۲ items) ·         Comprehension·         Expression۶. Social cognition (۳ items) ·         Social interaction·         Problem solving·         MemoryFor the Motor-FIM, the Eating, Bowel management, and Grooming items are known to be the easiest items for patients with stroke to accomplish, whereas Locomotion, Tub transfers, and Stair climbing are the most challenging items (Granger, Cotter, Hamilton, & Fiedler, ۱۹۹۳; Grimby, Gudjonsson, Rodhe, Sunnerhagen, Sundh, & Ostensson, ۱۹۹۶). For the Cognitive-FIM, performance of the Expression items has been found to be the easiest for patients to accomplish, and Problem solving has been found to be the most challenging (Granger et al., ۱۹۹۳).
Time:
The FIM is reported to take between ۳۰-۴۵ minutes to administer and score, with ۷ minutes to gather demographic information. Scoring:
Each item on the FIM is scored on a ۷-point Likert scale, and the score indicates the amount of assistance required to perform each item (۱ = total assistance in all areas, ۷ = total independence in all areas). A final summed score is created and ranges from ۱۸ - ۱۲۶, where ۱۸ represents complete dependence/total assistance and ۱۲۶ represents complete independence. Subscale scores for the Motor and Cognitive domains can also be calculated (Linacre, Heinemann, Wright, Granger, & Hamilton, ۱۹۹۴). The ratings are based on performance rather than capacity and can be acquired by observation, patient interview, telephone interview or medical records. The developers of the FIM recommend that the scoring be derived by consensus with a multi-disciplinary team.Granger, Deutsch, and Linn (۱۹۹۸) have applied a Rasch rating scale in order to transform the FIM’s ordinal ratings to an equal-interval rating scale so that it can be used for linear regression models. 

 

۱. In general, would you say
your health is:
Excellent ۱
Very good ۲
Good ۳
Fair ۴
Poor ۵

 

۲. Compared to one year ago,
how would your rate your health in general now?
Much better now than one year ago ۱
Somewhat better now than one year ago ۲
About the same ۳
Somewhat worse now than one year ago ۴
Much worse now than one year ago ۵

The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?(Circle One Number on Each Line)

Yes, Limited a Lot Yes, Limited a Little No, Not limited at All
۳. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports [۱] [۲] [۳]
۴. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf [۱] [۲] [۳]
۵. Lifting or carrying groceries [۱] [۲] [۳]
۶. Climbing several flights of stairs [۱] [۲] [۳]
۷. Climbing one flight of stairs [۱] [۲] [۳]
۸. Bending, kneeling, or stooping [۱] [۲] [۳]
۹. Walking more than a mile [۱] [۲] [۳]
۱۰. Walking several blocks [۱] [۲] [۳]
۱۱. Walking one block [۱] [۲] [۳]
۱۲. Bathing or dressing yourself [۱] [۲] [۳]

During the past ۴ weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?(Circle One Number on Each Line)

Yes No
۱۳. Cut down the amount of time you spent on work or other activities ۱ ۲
۱۴. Accomplished less than you would like ۱ ۲
۱۵. Were limited in the kind of work or other activities ۱ ۲
۱۶. Had difficulty performing the work or other activities (for example, it took extra effort) ۱ ۲

During the past ۴ weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?(Circle One Number on Each Line)

Yes No
۱۷. Cut down the amount of time you spent on work or other activities ۱ ۲
۱۸. Accomplished less than you would like ۱ ۲
۱۹. Didn’t do work or other activities as carefully as usual ۱ ۲

۲۰. During the past ۴ weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?(Circle One Number)Not at all ۱Slightly ۲Moderately ۳Quite a bit ۴Extremely ۵۲۱. How much bodily pain have you had during the past ۴ weeks?(Circle One Number)None ۱Very mild ۲Mild ۳Moderate ۴Severe ۵Very severe ۶۲۲. During the past ۴ weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?(Circle One Number)Not at all ۱A little bit ۲Moderately ۳Quite a bit ۴Extremely ۵These questions are about how you feel and how things have been with you during the past ۴ weeks. For each question, please give the one answer that comes closest to the way you have been feeling.How much of the time during the past ۴ weeks . . .(Circle One Number on Each Line)

All of the Time Most of the Time A Good Bit of the Time Some of the Time A Little of the Time None of the Time
۲۳. Did you feel full of pep? ۱ ۲ ۳ ۴ ۵ ۶
۲۴. Have you been a very nervous person? ۱ ۲ ۳ ۴ ۵ ۶
۲۵. Have you felt so down in the dumps that nothing could cheer you up? ۱ ۲ ۳ ۴ ۵ ۶
۲۶. Have you felt calm and peaceful? ۱ ۲ ۳ ۴ ۵ ۶
۲۷. Did you have a lot of energy? ۱ ۲ ۳ ۴ ۵ ۶
۲۸. Have you felt downhearted and blue? ۱ ۲ ۳ ۴ ۵ ۶
۲۹. Did you feel worn out? ۱ ۲ ۳ ۴ ۵ ۶
۳۰. Have you been a happy person? ۱ ۲ ۳ ۴ ۵ ۶
۳۱. Did you feel tired? ۱ ۲ ۳ ۴ ۵ ۶

۳۲. During the past ۴ weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?(Circle One Number)All of the time ۱Most of the time ۲Some of the time ۳A little of the time ۴None of the time ۵How TRUE or FALSE is each of the following statements for you.(Circle One Number on Each Line)

Definitely True Mostly True Don’t Know Mostly False Definitely False
۳۳. I seem to get sick a little easier than other people ۱ ۲ ۳ ۴ ۵
۳۴. I am as healthy as anybody I know ۱ ۲ ۳ ۴ ۵
۳۵. I expect my health to get worse ۱ ۲ ۳ ۴ ۵
۳۶. My health is excellent ۱ ۲ ۳ ۴ ۵