HDSA Center of Excellence at UC Davis Medical Center
Rev. 10/2013
HD CLINIC INTAKE FORM
Welcome to the HDSA Center of Excellence HD Clinic. Please take a moment to answer the questions
below as best as you can. If you need assistance, a caregiver/companion may complete this form for
you.
Date: _________________________________________________
GENERAL HEALTH:
Yes
No
1. Have you had any changes to your general health and/or hospitalizations since
your last visit with us?
If Yes, please describe?
2. Did you visit a doctor, emergency room or experience any injuries since your last
visit?
If yes, please describe?
Yes
No
3. Are you having trouble swallowing or choking/coughing on foods or liquids?
4. Have you experienced any weight loss since your last visit?
5. Have you had any falls?
6. Do you exercise regularly?
7. How many days per week do you exercise?
What type of exercise do you do?
8. Are you experiencing any difficulty with sleep?
(i.e. trouble falling asleep, staying asleep, restlessness, etc.)
If yes, please describe?
9.
Have you completed an Advance Health Care Directive, Living Will or Durable
Power of Attorney for Health Care?
--If no, would you like more information about this subject?
HDSA Center of Excellence at UC Davis Medical Center
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HDSA Center of Excellence at UC Davis Medical Center
Rev. 10/2013
MOVEMENT:
Yes
No
1. Are you having chorea?
If you answered YES, please use the scale below to answer the additional questions.
If you answered NO, please skip to Thinking Skills on this page.
Very
Disruptive
Not at all
2. How much is the chorea bothering you?
1
2
3
4
5
3. How much is it bothering your caregiver/partner?
1
2
3
4
5
4. How much does your chorea interfere with your
ability to do things?
1
2
3
4
5
THINKING SKILLS:
Have you or your companion/caregiver noticed any difficulties with the following tasks?
Yes
No
Keeping track of schedules and/or organizing things?
Being unaware of your HD symptoms?
Not understanding things that are said to you?
Having trouble concentrating or paying attention?
Having trouble initiating activities or conversations?
Problems with memory?
Any difficulties with speaking or making conversation?
Keeping track of appointments and/or taking your medications?
FUNCTIONAL STATUS:
Are you having any difficulties in your ability to do any of the following activities?
Yes
No
Describe difficulties
Ability to work
Managing money/finances
Ability to do usual chores
Ability to perform grooming,
bathing or dressing
Ability to feed yourself
Ability to drive safely
Do you need caregiving help from
your family member or others?
HDSA Center of Excellence at UC Davis Medical Center
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HDSA Center of Excellence at UC Davis Medical Center
MEDICAL EQUIPMENT: Are you currently using any medical assistive devices?
Yes
No
Cane
Bathroom rails/safety bars
Walker
Raised toilet seat
Wheelchair
Bath/Shower bench or chair
Bedside Commode
Hand held shower nozzle
Hospital Bed
Other ___________________
Rev. 10/2013
Yes
No
MOOD: Have you or your family noticed any difficulties in your mood or behavior since your last visit?
None
Mild
Moderate
Severe
Sadness/Depression
Irritability
Anxiety
Anger outbursts or aggression
Obsessional thoughts
Compulsive behaviors
Apathy (lack of energy)
Impulsiveness
Difficulty initiating activities
Have you experienced any suicidal thoughts since your last medical
visit?
None
Fleeting
Actively
Planning
**Please also complete the PHQ-9 on the following page with additional questions about your mood.**
HD RESEARCH:
Yes
No
Maybe
Are you interested in participating in HD Research at this time?
Would you give your permission to be contacted in the future
about research you may be eligible for?
Please complete the information below if you are willing to be contacted for HD research?
Name:
Address:
Contact Numbers:
Signature:
HDSA Center of Excellence at UC Davis Medical Center
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HDSA Center of Excellence at UC Davis Medical Center
Rev. 10/2013
Patient Health Questionnaire (PHQ-9)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
(Please put an “X” to indicate the best answer)
More
than half
the days
Nearly
every day
Not at all
Several
days
1.
Little interest or pleasure in doing things
0
1
2
3
2.
Feeling down, depressed or hopeless
0
1
2
3
3.
0
1
2
3
4.
Trouble falling or staying asleep, or sleeping
too much
Feeling tired or having little energy
0
1
2
3
5.
Poor appetite or overeating
0
1
2
3
6.
Feeling bad about yourself—or that you are a
failure or have let yourself or your family
down
Trouble concentrating on things, such as
reading the newspaper or watching television
Moving or speaking so slowly that other
people could have noticed. Or the
opposite—being so fidgety or restless that
you have been moving around a lot more
than usual
Thoughts that you would be better off dead,
or of hurting yourself in some way
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
7.
8.
9.
Add columns
+
+
TOTAL
10. If you checked off any problems, how difficult have these problems
made it for you to do your work, take care of things at home or get
along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Janet B.W. Villiams, Kurt Kroenke, and colleagues, with an
educational grant from Pfizer Inc. For research information, contact Dr. Spitzer at rls8@columbia.edu. Use of the PHQ-9 may only be made in
accordance with the Terms of Use available at http://www.pfizer.com. Copyright 1999 Pfizer Inc. All rights reserved. PRIME MD TODAY is a
trademark of Pfizer, Inc.
Are there any other issues you would like to discuss today?
HDSA Center of Excellence at UC Davis Medical Center
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