Comorb ques, appen B 3/29



TOTAL SCORE______________

COMORBIDITY QUESTIONNAIRE Date__________

(from Katz et al., 1996, interview form based on Charlson)

Participant ID_________

Myocardial infarction: (total score possible: 1)

1. Have you ever had a heart attack? Yes No score 1 _____

Congestive heart failure: (total score possible: 1)

2. Have you ever been treated for heart failure? (You may have been short of breath and the doctor may have told you that you had fluid in your lungs or that your heart was not pumping well.)

Yes No score 1 _____

Peripheral vascular disease: (total score possible: 1)

3. Have you had an operation to unclog or bypass the arteries in your legs?

Yes No score 1 ______

Cerebrovascular accident: (total score possible: 1)

4. Have you had a stroke, cerebrovascular accident, blood clot or bleeding in the brain, or transient ischemic attack (TIA)?

Yes No score 1 ______

Hemiplegia: (total score possible: 2)

4a. Do you have difficulty moving an arm or leg as a result of the stroke or

cerebrovascular accident?

Yes No score 2 _____

Chronic obstructive pulmonary disease: (total score possible: 1)

5. Do you have asthma? Yes No

If yes, do you take medicines for your asthma? No

a.) Yes, with flare-ups of asthma only Yes

b.) Yes, I take medicines regularly, even when I’m not having a flare-up Yes

6. Do you have emphysema, chronic bronchitis, or chronic obstructive lung disease?

Yes No

If yes, do you take medicines for your lung disease? No

c.) Yes, only with flare-ups Yes

d.) Yes, I take medicines regularly, even when I’m not having a flare-up

Yes

Any yes to a.), b.), c.), or d.) score 1 _____

Ulcer disease: (total score possible: 1)

7. Do you have stomach ulcers, or peptic ulcer disease?

Yes No

If yes, has this condition been diagnosed by endoscopy (where a doctor looks into your stomach through a scope) or an upper GI or barium swallow study (where you swallow chalky dye and then x-rays are taken)?

Yes No

score 1 _____

Diabetes: (total score possible: 3)

8. Do you have diabetes (high blood sugar)?

Yes No

a.) Yes, treated by medications taken by mouth Yes

b.) Yes, treated by insulin injections Yes

Any yes to a.) or b.) score 1 _____

8a. Has the diabetes caused any of the following problems?

Problems with your kidneys Yes No

Problems with your eyes, treated by an ophthalmologist

Yes No Any Yes score 2 _____

Renal: (total score possible: 2)

9. Have you ever had the following problems with your kidneys?

Poor kidney function (blood tests show high creatinine) Yes No

Have used hemodialysis or peritoneal dialysis Yes No

Have received kidney transplantation Yes No

Any Yes score 2 _____

Connective tissue disease: (total score possible: 1)

10. Do you take regular medicine for rheumatic arthritis? (do not count osteoarthritis)

Yes No

Do you have Lupus (systemic lupus erythematosus)?

Yes No

Any Yes score 1_____

Dementia, liver disease, leukemia, lymphoma, tumor, metastases, AIDS:

11. Do you have any of the following conditions?

Alzheimer’s Disease, or another form of dementia? Yes No score 1_____

Cirrhosis, or serious liver damage? Yes No score 3 _____

Leukemia or polycythemia vera? Yes No score 2 _____

Lymphoma? Yes No score 2 _____

Cancer, other than skin cancer, leukemia, or lymphoma? Yes No

If yes, has the cancer spread, or metastasized to other parts of your body?

Yes No score 6_____

If the cancer has NOT metastasized, was the cancer first treated less than 5 years ago? Yes No score 2 _____

AIDS Yes No score 6 _____

Osteoarthritis: (total score possible: 1)

12. Do you have osteoarthritis? Yes No

If yes, do you take medications for it regularly? Yes No score 1_____

Thyroid: (total score possible: 1)

13. Do you have a problem with your thyroid? Yes No

If yes, is it hypothyroid? Yes No score 1_____

Hearing Problems: (total score possible: 1)

14: Can you only hear shouted words, or do you have difficulty hearing in crowded places, or do you often depend on reading lips? Answer yes if any of these is true.

Yes No score 1_____

Vision Problems: (total score possible: 1)

15: Can you only see outlines of objects and people, or do you need help in cooking, eating, dressing, bathing or going to the toilet because you have trouble seeing? Answer yes if any of these is true.

Yes No score 1_____

Urinary Problems: (total score possible: 1)

16: Do you frequently lose urine, to the extent that it keeps you from going out or engaging in activities at home that you would like to do?

Yes No

Do you have an indwelling urinary catheter, urinary condom, or do you wear a heavy pad to catch urine? Do not count light pads, such as panty liners.

Yes No

Any yes score 1______

TOTAL SCORE_______

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