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Primary Care Tools for Clinicians - A Compendium of Forms, Questionnaires, and Rating Scales for Everyday Practice
By Lorraine Loretz, DPM, MSN, FNP
Approx. 512 pages, Illustrated, Copyright 2005
ISBN:0323019838
Description
This unique collection of tools for primary care clinicians features over 230 forms, scales, and inventories to use or adapt for routine or specialized exams. Designed to save time and assist busy practitioners, Primary Care Tools for Clinicians guides standardized assessment and documentation a patient's condition by providing ready-to-use forms that represent the "gold standard" of current practice. Previously published rating scales and measures useful in primary care are also collected here within specialty focused chapters. An accompanying CD-ROM includes over 200 of the tools in electronic format, including 52 customizable forms that users can modify for their own practice. Lists of resources direct readers to further information on clinical topics or sources for additional forms and tools.
Key Features
A wide range of physical examination forms are included, such as histories and physicals across the lifespan, patient logs and records, sports physicals, psychiatric forms, nutrition forms, and other specialized exams.
Over 140 developmental and pediatric tools, behavioral instruments, geriatric measures, quality of life and functional ability instruments, pain scales, wound classifications, nutrition assessment tools, system-specific measures, and social and spiritual rating scales are provided.
Each tool is accompanied by a description and explanation of its uses, which includes the authors, sources, scoring, targeted populations, administration time, and reliability and validity where applicable.
Extensive online resources and print references are provided for further information on proprietary measures, documentation support, professional organization recommendations, and government healthcare agency guidelines.
Icons identify which forms can be adapted for use and which forms and measures can also be found in electronic format on the accompanying CD-ROM.
Pages are perforated and 3-hole punched for easy tear-out, photocopying, customization, or placement into a binder.
Over 200 forms and measures are included on an accompanying CD-ROM, 57 of which are customizable, and can be printed and copied for use in any office.
Table of Contents
PART ONE: HISTORY, PHYSICAL EXAMINATION AND RELATED FORMS Introduction to Part One CHAPTER 1: Adult History and Physical Examination Forms • Comprehensive Adult History and Physical Form • Adult History and Physical Form – Female • Adult History and Physical Form – Male • Adult History and Physical – Female Short Form • Adult History and Physical – Male Short Form • Well-Woman History and Physical Form • Comprehensive Older Adult History & Physical Form • Office Visit Form • Medication History • CHAPTER 2: Patient Information Logs and Records • Adult Health Profile • Adult Health Care Maintenance Record • Medication Log • Medication Refill Log • Injection Record • Adult Vaccine and PPD Administration Record • Pediatric Vaccine and PPD • Administration Record • Laboratory Results Log • X-Ray and Special Procedure Results Log • Coagulation Monitoring Log • Blood Pressure Log • Vital Signs Flow Sheet • Diabetes Monitoring Log • Asthma Monitoring Log • Triage Call Record • CHAPTER 3: Pediatric History and Physical Examination Forms and Tools • Pediatric History and Physical Forms: Initial Health Questionnaire • 0-1 month to 18-20 year visit • Pediatric Well-Care summaries: 2 weeks to 16-17 years • Early Breastfeeding Screening Form • Breastfed Newborn Triage Form • Lead Screening Risk Questionnaire • Tuberculosis Risk Assessment Questionnaire • Adolescent Risk Monitoring Log • Adolescent Health Profile • HEADSSS • SAFETEENS • CHAPTER 4: Sports History and Physical Examination Forms • Preparticipation Physical Evaluation Form • Preparticipation Physical Evaluation Clearance Form • Medical Conditions and Sports Participation • Physical Activity Readiness Questionnaires • Patient-Runner History Form • Special Olympics Athlete Application for Participation Sample • CHAPTER 5: Psychiatric Histories and Related Forms • Mental Health Assessment Form • Child Psychiatry Emergency Consultation • Mental Status Examination Checklist • Substance Use History and Physical Examination Form • Substance Abuse History Form • Daily Mood Chart • Abuse Assessment Screen • Partner Violence Screen • Spouse Abuse-Assessing Level of Violence in the Home • SAFE Technique • RADAR Screening Tool • SIG E CAPS • SALSA • BATHE • HOPE • SPIRIT • ETHNIC CHAPTER 6: Nutrition Forms • General Nutritional Assessment Forms: Level I Screen • Level II Screen • Determine Your Nutritional Health • Medications Use Checklist • Nutrition History • General Food Frequency Questionnaire • Food Intake Record • Nutrition History Form • Initial Nutrition Assessment Form • Food Diary • One-Day (24 Hour) Record of Food Intake • Perinatal Nutrition Screening/Assessment Form • Eating Disorder Nutritional Assessment Form • Herbal, Botanical and Dietary Supplement Intake Form CHAPTER 7: Specialized Evaluation Forms • Preoperative Evaluation: Stepwise Approach to Preoperative Cardiac Assessments • American Society of Anesthesiologists (ASA) Physical Status Classification • Pre-Operative Clearance Evaluation Form – Adult • Pre-Operative Clearance Evaluation Form – Pediatric • • Commercial Driver Fitness Evaluation: US Department of Transportation (DOT) Medical Examination Report for Commercial Driver Fitness Determination • Physical Qualifications for Drivers • Instructions to the Medical Examiner: Federal Motor Carrier Safety Regulations –Advisory Criteria • Medical Examiner’s Certificate • • Evaluation for Adjustment of Immigrant Status: US Department of Homeland Security (DHS), US Citizenship and Immigration Services (USCIS) Medical Examination of Aliens Seeking Adjustment of Status • Medical Clearance Requirements for Aliens Seeking Adjustment of Status • PART TWO: ASSESSMENT SCALES AND INVENTORIES Introduction to Part Two CHAPTER 8: Developmental and Pediatric Tools • Maturational Assessment of Gestational Age (New Ballard Score) • Centers for Disease Control and Prevention 2000 Growth Charts for the United States: Boys and Girls 0-36 months: Length for age/Weight for age, Head circumference for age/Weight for length; Boys and Girls 2-20 years: Stature for age/Weight for age, Body mass index for age, Weight for stature • Growth Charts for Children with Down Syndrome: Weight & Length: Birth – 3, boys and girls; Weight & Height: 2-18, boys and girls; Head circumference: Birth – 3, boys and girls • Tanner Stages of Development • Apgar Scoring System • Baby Check Scoring System • Diagnostic Criteria for Prader-Willi Syndrome • Injury Behavior Checklist • The Injury Prevention Program (TIPPTM) • Framingham Safety Surveys • Developmental Screening Tool Reviews and Sources: Ages and Stages Questionnaires (ASQ™) • Child Development Inventories (CDI) • Parents’ Evaluation of Developmental Status (PEDS) • Batelle Developmental Inventory (BDI) Screening Test • Bayley Infant Neurodevelopmental Screener® (BINSTM) • Early Screening Inventory – RevisedTM (ESI-RTM) • Brigance Screens • Denver Developmental Materials • Checklist for Autism in Toddlers (CHAT) • Modified Checklist for Autism in Toddlers (M-CHAT) • Pediatric Symptom Checklist (PSC) • Family Psychosocial Screening • Safety Word Inventory and Literacy Screener (SWILS) • Dyslexia Early Screening Test (DEST) • Dyslexia Screening Test (DST) • Dyslexia Adult Screening Test (DAST) • NICHQ ADHD Practitioners' Toolkit • Conners’ Rating Scales-Revised • Online Resources • CHAPTER 9: Behavioral and Psychiatric Instruments • Global Assessment of Functioning Scale (GAF)/ Global Assessment Scale (GAS) • POSIT • Center for Epidemiologic Studies-Depression Scale (CES-D) • Center for Epidemiologic Studies-Depression Scale for Children (CES-DC) • Hamilton Rating Scale for Depression (HRSD) • Montgomery Åsberg Depression Rating Scale (MADRS) • Primary Care Evaluation of Mental Disorders: Patient Health Questionnaire 9-Item Depression Module (PRIME-MD PHQ-9) • Zung Self-Rating Depression Scale (SDS) • Edinburgh Postnatal Depression Scale (EPDS) • Geriatric Depression Scale (GDS) • Cornell Scale for Depression in Dementia (CSDD) • Hamilton Anxiety Rating Scale (HARS) • Zung Self-Rating Anxiety Scale (SAS) • Yale-Brown Obsessive Compulsive Scale (Y-BOCS) • Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) • Screening Test for Obsessive-Compulsive Disorder • Liebowitz Social Anxiety Scale (LSAS) • Recent Life Changes Questionnaire (RLCQ) • Overt Aggression Scale – Modified (OAS-M) • Rating Scale for Aggressive Behavior in the Elderly (RAGE) • HITS • Modified SAD PERSONS Scale • 4-Item Risk of Suicide Questionnaire (RSQ-4) • CAGE Questionnaire • TACE Questionnaire • Michigan Alcoholism Screening Test (MAST) • Alcohol Use Disorders Identification Test (AUDIT) • Drug Abuse Screening Test (DAST) • CRAFFT • SCOFF Questionnaire • Eating Disorder Screen for Primary Care (ESP) • Eating Attitudes Test (EAT-26) • Psychiatric Tool Reviews and Sources: Beck Depression Inventories (BDI, BDI-II, BDI-FS) • Reynolds Child Depression Scale (RCDS) • Reynolds Adolescent Depression Scale-2nd Edition (RADS-2) • Beck Anxiety Inventory (BAI) • Beck Scale for Suicidal Ideation (BSS) • Beck Hopelessness Scale (BHS) • Suicide Probability Scale (SPS) • Suicidal Ideation Questionnaire (SIQ) • Eating Disorders Inventory – Second Edition (EDI-2) • CHAPTER 10: Geriatric Assessment Tools • Instrumental Activities of Daily Living Scale (IADL) • Structured Assessment of Independent Living Skills (SAILS) • Brief IADL Measure • Hearing Handicap Inventory for the Elderly--Screening Version (HHIE-S) • Tinetti Balance and Gait Evaluation/Performance-Oriented Assessment of Mobility • Get Up and Go Test • Timed Up and Go Test • Risk Assessment Tool (RAT) for Falls • Reassessment is Safe "Kare" (RISK) Tool • Guidelines for Home Safety Assessment • Environmental Assessment for the Elderly • Driving Skills Quiz • Brief Abuse Screen for the Elderly (BASE) • Caregiver Abuse Screen (CASE) • Blessed Dementia Scale and Information-Memory-Concentration (IMC) Test • FROMAJE Mental Status Guide • Set Test • Clock Drawing Test • 6-Item Cognitive Impairment Test • Hachinski Ischemic Score for Multi-Infarct Dementia • Geriatric Tool Reviews and Sources: Mini-Mental State Examination (MMSE) • Dementia Tools Online • Agitation Scales Online • OARS Multidimensional Functional Assessment Questionnaire • CHAPTER 11: Health Status Measures • Spitzer’s Quality of Life (QL) Index • COOP Charts for Primary Care Practice • The Duke Health Profile • Arthritis Impact Measurement Scales (AIMS) • Barthel Index • Katz Activities of Daily Living • Functional Status Index (FSI) • Functional Independence Measure (FIM) • Pain Disability Index (PDI) • Health Status Tool Reviews and Sources: Sickness Impact Profile (SIP) • MOS SF-36, MOS SF-12 • Nottingham Health Profile • Stanford Health Assessment Questionnaire • CHAPTER 12: Pain Scales • Verbal Descriptor Scale • Numeric Rating Scale • Visual Analogue Scale • Body Outline Tool • Wong/Baker Faces Rating Scale • Oucher Scales • Faces Pain Scale-Revised • McGill Pain Questionnaire-Long and Short Forms • Brief Pain Inventory – Short Form • CHEOPS • NIPS • Geriatric Pain Assessment Form • CHAPTER 13: Wound Classification Systems and Risk Assessment Tools • National Pressure Ulcer Advisory Panel (NPUAP) Staging System for Pressure Ulcerations • Pressure Ulcer Scale for Healing (PUSH Tool) • Wagner Classification • University of Texas Diabetic Wound Classification System • Norton Pressure Ulcer Prediction Scale • Braden Scale for Predicting Pressure Sore Risk • CHAPTER 14: Nutrition Tools • Body-Mass Index (BMI) • Height and Weight Assessment • Mini Nutritional Assessment Tool • USDA Food Guide Pyramid • Food Pyramid for Children • Willet’s New Food Guide Pyramid • Vegetarian Food Guide Pyramid • Other Food Pyramid Resources • CHAPTER 15: System Specific Assessment Tools • New York Heart Association (NYHA) Classification for Congestive Heart Failure (CHF) • American College of Cardiology (ACC)/American Heart Association (AHA) 2001 Guidelines: Stages of Heart Failure • FACES Screening Tool for Heart Failure • Revised Cardiac Risk Index • Snellan Visual Acuity Chart • Rosenbaum Chart • Amsler Grid • Self Assessment Hearing Test • Burke Dysphagia Screening Test (BDST) • Epworth Sleepiness Scale • Glasgow Coma Scale • Migraine Disability Assessment (MIDAS) Questionnaire • Headache Diary • Berg Balance Scale • Abnormal Involuntary Movement Scale (AIMS) • Stroke Scales Resources • Rhodes Inventory of Nausea and Vomiting – Revised (INVR) • Constipation Assessment Scale (CAS) • Androgen Deficiency in Aging Males (ADAM) Questionnaire • Brief Male Sexual Function Inventory for Urology • American Urological Association (AUA) Symptom Index • Incontinence Impact Questionnaire (IIQ-7) and Urogenital Distress Inventory (UDI-6) • CHAPTER 16: Social and Spiritual Assessment Tools • The Family APGAR • Zarit Burden Interview • Support for Caregivers Questionnaire • Duke UNC Functional Social Support • Lubben Social Network Scale • UCLA Loneliness Scale • Jarel Spiritual Well-Being • Survey of Pain Attitudes (SOPA) • Social-Spiritual Tool Reviews and Sources: MOS-SSS • Spiritual Involvement and Beliefs Scale (SIBS) • Spiritual Well-Being Scale (SWBS) • Index of Core Spiritual Experiences (INSPIRIT) • Appendix A: How to modify forms on CD-ROM Appendix B: Abbreviations used Appendix C: Permissions resources for copyrighted tools
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