Kourage Health Reassessment Encounter

Qualifying Information - Exercise Specialist enters information

Encounter Type

Encounter Date

Participant Case Number

Must have leading zeros

Kourage Health Location

Assessment Number

Assessment Performed By

Survey Type

Fact-G Quality of Life

Below is a list of statements that other people with your illness have said are important. Please mark one number per line to indicate your response as it applies to the past 7 days.

Physical Well-Being

	Not at all	A little bit	Some-what	Quite a bit	Very much
I have a lack of energy
I have nausea
Because of my physical condition, I have trouble meeting the needs of my family
I have pain
I am bothered by side effects of treatment
I feel ill
I am forced to spend time in bed

Social/Family Well-Being

	Not at all	A little bit	Some-what	Quite a bit	Very much
I feel close to my friends
I get emotional support from my family
I get support from my friends
My family has accepted my illness
I am satisfied with family communication about my illness
I feel close to my partner (or the person who is my main support)

	No
Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please mark this box and go to the next section

Emotional Well-Being

	Not at all	A little bit	Some-what	Quite a bit	Very much
I feel sad
I am satisfied with how I am coping with my illness
I am losing hope in the fight against my illness
I feel nervous
I worry about dying
I worry that my condition will get worse

Functional Well-Being

	Not at all	A little bit	Some-what	Quite a bit	Very much
I am able to work (include work at home)
My work (include work at home) is fulfilling
I am able to enjoy life
I have accepted my illness
I am sleeping well
I am enjoying the things I usually do for fun
I am content with the quality of my life right now

Fact-GP - General Population - V4

Below is a list of statements that other people with your illness have said are important. Please mark one number per line to indicate your response as it applies to the past 7 days.

Physical Well-Being

	Not at all	A little bit	Some-what	Quite a bit	Very much
I have a lack of energy
I have nausea
Because of my physical condition, I have trouble meeting the needs of my family
I have pain
I feel ill
I am forced to spend time in bed

Social/Family Well-Being

	Not at all	A little bit	Some-what	Quite a bit	Very much
I feel close to my friends
I get emotional support from my family
I get support from my friends
I feel close to my partner (or the person who is my main support)

	No
Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please mark this box and go to the next section

Emotional Well-Being

Functional Well-Being

	Not at all	A little bit	Some-what	Quite a bit	Very much
I am able to work (include work at home)
My work (include work at home) is fulfilling
I am able to enjoy life
I am sleeping well
I am enjoying the things I usually do for fun
I am content with the quality of my life right now

FACIT Fatigue Scale

Below is a list of statements that other people with your illness have said are important. Please mark one number per line to indicate your response as it applies to the past 7 days.

	Not at all	A little bit	Some-what	Quite a bit	Very much
I feel fatigued
I feel weak all over
I feel listless ("washed out")
I feel tired
I have trouble starting things because I am tired
I have trouble finishing things because I am tired
I have energy
I am able to do my usual activities
I need to sleep during the day
I am too tired to eat
I need help doing my usual activities
I am frustrated by being too tired to do the things I want to do
I have to limit my social activity because I am tired

Thank you for filling out the Quality of Life surveys! Please ask your Exercise Specialist to assist you with the next question.

Exercise Specialist, please indicate if the survey should be submitted from this point, or continue on to complete the reassessment encounter.

Physical Assessment

Godin Leisure Time Questionnaire

Godin - Strenuous Exercise (Heart Beats Rapidly)

(e.g., Running, hockey, jogging, football, cross country skiing, soccer, basketball, vigorous swimming, vigorous long-distance bicycling)

Godin - Moderate Exercise (Not Exhausting)

(e.g., Fast walking, baseball, tennis, easy bicycling, volleyball, badminton, easy swimming, folk dancing)

Godin - Mild/Light Exercise (Minimal Effort)

(e.g., Yoga, archery, fishing, horseshoes, bowling, golf, easy walking)

Vitals Information

Oxygen Saturation - Pre-Exercise

Oxygen Saturation - Mid Point

Oxygen Saturation - Post-Exercise

Blood Pressure - Pre-Exercise

Blood Pressure - Post-Exercise

Height

In Inches

Weight

In Pounds

Girth

In Centimeters

Temperature

Heart Rate - Pre-Exercise

Heart Rate - Mid Point

Heart Rate - Post-Exercise

Heart Rate Recovery

Rate of Perceived Exertion

Neurologic Motor Exam

Shoulder - Left

Shoulder - Right

Biceps - Left

Biceps - Right

Triceps - Left

Triceps - Right

Grip - Left

Grip - Right

Hip Flexors - Left

Hip Flexors - Right

Quads - Left

Quads - Right

Hamstrings - Left

Hamstrings - Right

Plantar Flexion - Left

Plantar Flexion - Right

Dorsi Flexion - Left

Dorsi Flexion - Right

Physical Assessment

Hand Grip Score

Hand Grip Side

Functional Reach - 1

Functional Reach - 2

6 Minute Walk Test

Distance in Miles

Reassessment Scheduled

Yes - create a Salesforce event with appointmentNo - send a Salesforce task to your manager

Progression / Encounter Notes

Submission Page

This will complete this reassessment, import directly into Salesforce, and create the new encounter within the patient's case. Go to the newly created encounter to complete entering in the reassessment information.