| B. Differential Diagnosis |
Degree of
Difficulty
|
Score |
|
|
None |
Slight |
Some |
Much |
Very |
|
| 1.
Pain, stiffness, or aching in your joints (ankles, knees, or
hips)? |
4 |
3 |
2 |
1 |
0 |
| 2. Weakness in one or both of your
legs? |
4 |
3 |
2 |
1 |
0 |
| 3. Pain or discomfort in your
chest? |
4 |
3 |
2 |
1 |
0 |
| 4. Shortness of
breath? |
4 |
3 |
2 |
1 |
0 |
| 5. Heart
palpitations? |
4 |
3 |
2 |
1 |
0 |
| 6. Other problems? (Please
list) |
4 |
3 |
2 |
1 |
0 |
|