Form Builder Templates with Pre-Calculated Values

Form Builder Templates with Pre-Calculated Values

Within the form builder we have created standard PRO/scoring specific forms. The values set are intended to adjust with your document if you add/remove components. These forms are available to provider users as a template, they can also be used for surveys.

Pain self efficacy Questionnaire (PSEQ)

Assess confidence to complete activity at present despite pain. Total score calculated.

The Roland-Morris Low Back Pain and Disability Questionnaire 

Assess self-rated physical disability caused by low back pain. Total count selected will autoscore.

Eating Attitudes Test (EAT-26)

Screening measure to help determine disordered eating that needs attention from a professional. A score of 20 or more indicates the need for referral.

Knee Injury and Osteoarthritis Outcome Score (KOOS)

A self-reported outcome measure to assess the patient's opinion about the health, symptoms, and functionality of their knee. Each category (Pain, Symptoms, ADL, Sport/Rec and QOL) will auto-calculate the score. Traditionally a score of 100 indicates no problems and a score closer to 0 indicates extreme problems.

Foot and Ankle Ability Measure (FAAM)

A self-reported measure that assesses physical function of individuals with lower leg, foot, and ankle musculoskeletal disorders. Auto-calculated value will give you the level of function with 0% being the least function to 100% being the most function.

Oswestry Low Back Disability Questionnaire

A self-reported measure that is used to measure the patients permanent functional disability of the lower back. Auto-calculated values will give you an overall score 0-50, 0 being no disability, and 50 being complete disability.

The DASH

A Self-reported outcome tool that attempts to determine the amount of difficulty a patient has when doing an activity. Auto-calculated values will produce an overall score of 0-100 a higher score will indicate a greater level of disability and severity, whereas, a lower score indicates a lower level of disability

QuickDASH

A condensed version of the full DASH Instead of 30 items, the QuickDASH uses 11 items to measure physical function and symptoms in people with any or multiple musculoskeletal disorders of the upper limb.

The Lower Extremity Functional Scale

A self-reported measure of the patients ability to perform daily tasks. It can also be used to measure initial function, ongoing progress and outcome, as well as set goals. Auto-calculated vales will range from 0-80, the higher the score the greater the disability.

The Cumberland Ankle Instability Tool (CAIT) Questionnaire

A scale to measure the severity of functional ankle instability. Auto-calculated values will give a range from 0-30. A higher score indicates a higher stability.

Disablement in the Physically Active Scale

A patient reported scale a for a physically active individual who suffers from musculoskeletal injury while participating in sport and exercise. Auto-calculated values will give you a mental score as well as an overall score.

Par-Q (Short Version)

A self-reported method of uncovering health and lifestyle issues prior to starting an exercise program. Auto-calculated values for this form will produce conditionals- 1+/7 "Yes" responses are selected, a disclaimer is produced. If the patient responds "No" to 7/7, the patient then signs the document.

The Cannabis Use Disorder Identification Test - Revised (CUDIT-R)

A self-reported method of identifying cannabis use/disorder. Auto-calculated values for this form will give you a total score. It's standard that a score of 8 or more indicates hazardous cannabis use while a score 12 or higher indicates possible cannabis use disorder.

AUDIT Alcohol Screening Tool

A self-reported screening for unhealthy alcohol use, defined as risky or hazardous consumption or any alcohol use disorder. Auto-calculated values will produce a total score out of 40. 0 indicates no concern, 1-7 low risk, 8-12 risky, and 13+ indicates a high risk of alcohol use.

PHQ-9

Self-reported diagnostic tool to screen for the presence and severity of depression. Auto-calculated values will range from 0-27. It's standard that 0-4 equals "normal", 5-9 indicates mild depression, 10-14 indicates moderate depression, 15-19 indicates moderately severe depression, and 20+ indicates severe depression.

Columbia-Suicide Severity Rating Scale (C-SSRS)

A is a suicidal ideation and behavior rating scale. Answers to questions 4, 5, or 6 will trigger a conditional component with instructions for further care.

Daily Concussion Symptom Checklist

Symptom checklist from the SCAT-5 for daily monitoring. The total number of symptoms/22 and symptom severity score/132 will auto-calculate.

Psychological Readiness to Return to Sport Scale

Confidence rated questionnaire. Scores between 50 and 60 suggest the patient is ready to return; below 50 suggest the patient may not be prepared to return to activity.