ALTITUDE RISK PREDICTION STUDY.
A multicentre prospective evaluation of self-assessed risk predictors at high altitude.
Purpose
This questionnaire is for evaluation only, not for clinical use.
After evaluation in large-scale prospective studies, a small subset of these questions will be used
to predict risk of serious altitude illness. The endpoint is intended to be easy to use for
laypeople, and to provide a risk score without any need for clinical examination or
measurement. The number of points given to each symptom will change following prospective
large-scale evaluation of this tool. In order to provide accurate, generalizable quantification of
risk, this questionnaire must be systematically evaluated in multi-center studies.
Study Design: cohort study
Accurate follow-up recording is essential.
Subjects will be recruited at any time before or during travel to high altitude. The duration of
each study will be decided in advance, and will range from 1 to 20 days. Questionnaires will be
completed at least once per day for the duration of the study. The primary endpoint is
unplanned descent for any reason.
A record will be kept of all subjects who are recruited to each study. Careful follow-up is
essential to ensure that 100% of subjects recruited complete the questionnaires as planned until
(a) they complete the planned study period, or (b) they record an unplanned descent.
Results will be analysed according to a prospectively-determined statistical analysis plan.
Availability
All past versions, and the current version, of this questionnaire will be stored in perpetuity and
will remain freely downloadable from altitude.org/ams
Reporting
This document was created by volunteers from the international scientific community. It is free
to use for any purpose. We would respectfully suggest that, at the time of publication of any
results of audit or research using this tool, full subject-level data, in an electronically readable
format, should be made freely available to the global community.
DAILY SYMPTOM RECORD
Altitude sickness risk score (ASRS) v0.26
FOR EVALUATION ONLY
Please circle one statement in each row that
most closely applies to you.
SELFASSESSMENT
0
1
Wellness
Headache
(severity)
Name/identifier:
Date:
Time:
2
3
I feel well
I feel
moderately
unwell
I feel very
unwell
I feel worse
than at any
other time in
my life
None or mild
Moderate
headache
Severe
headache
The worst
headache I can
imagine
Mainly at the
side/sides of my
head
Mainly at the
back of my
head
All over my
head
None or mild
(not feeling
nauseated)
Moderate
nausea
Severe nausea
Worst nausea I
have ever had
No vomiting in
last 24h
I have vomited
once in the last
24h
I have vomited
2-3 times in
last 24h
I have vomited
4 or more
times in last
24h
Good night’s
sleep
Slightly
disturbed sleep
Moderately
disturbed
sleep
Terrible
night’s sleep
Not exhausted
Slightly
exhausted
Very
exhausted
Completely
exhausted
Cough
No cough
Any cough
Moderate
cough
Severe cough
Cough (type)
No cough
Dry cough (not
coughing
anything up)
Coughing up
sputum
Coughing up
blood
Comparison
with others
I feel better
than most
About average
I feel worse
than most
I feel worse
than everyone
else
If you have a
Mainly at the
headache, where front of my
head
is it worst?
Nausea (the
sensation of
needing to
vomit)
Vomiting
Sleep
Exhaustion
Unsteadiness
Breathlessness
None
Slightly
Very unsteady
unsteady on feet
on feet
Unable to
stand without
help
None or only
on substantial
exertion
Breathless
Breathless
walking slowly walking slowly
uphill
on flat surface
Breathless at
rest
SCORE
Total score:
Altitude sickness risk score (ASRS)
FOR EVALUATION ONLY
Please ask any other person to complete this questionnaire regarding your performance.
DAILY
EXTERNAL
ASSESSMENT
0
1
2
Comparison
with others
He/she is doing better
than most
His/her performance is
about average
He/she is doing worse than
most
Breathing
He/she appears out of
He/she appears to be out of
breath only when
breath when walking on a
walking/climbing
flat surface
uphill
He/she appears to be out of
breath at rest
Unsteadiness
He/she is completely
steady
He/she seems to be a little
unsteady when standing or
walking
He/she seems to be quite
unsteady when standing or
walking
SCORE
Total score:
BASELINE
INFORMATION
Past history
HACE
No previous history of
high altitude cerebral
edema (HACE), or
don’t know
I believe I have previously had
high altitude cerebral edema
(HACE)
Past history
HAPE
No previous history of
high altitude
pulmonary edema
(HAPE)
I believe I have previously had
high altitude pulnonary edema
(HAPE)
Speed of ascent
in last 3 days
Less than 1000m
< 3280feet
Any nose or
chest infection
in last 7 days
None
Recent nose/chest infection
(eg. cough/cold/ vomiting)
Female
Male
Sex
More than 1000m
> 3280feet
More than 2000m
> 6560feet
Physical fitness
(normally at
home)
I’m normally quite
I’m normally about average
unfit for my age group
for people my age
I’m normally fitter than most
people my age
Other illnesses
Any other illness for which I
currently have a
prescription from a doctor
(eg. inhalers, tablets)
I have another illness that
normally limits my ability to
exercise
No other illnesses
Please record your outcomes for today:
TICK BOX
OUTCOME ASSESSMENT - TODAY
CONTINUING AS PLANNED:
CHANGING PLANS:
UNPLANNED DESCENT FOR ANY REASON:
IF UNPLANNED DESCENT OR CHANGE OF PLANS, PLEASE SPECIFY REASON:
SUSPECTED HIGH ALTITUDE CEREBRAL EDEMA (HACE)
SUSPECTED HIGH ALTITUDE PULMONARY EDEMA (HAPE)
SUSCPECTED ACUTE MOUNTAIN SICKNESS
ACCIDENT OR INJURY
OTHER REASON (please describe in free text):
TICK BOX