Attachment 10 - Scoring ALSFRS

Self-Administered ALS Functional Rating Scale-Revised

Patient Name: ___________________________ Date: ________________________

Scoring Sheet (for use by the health 1. SPEECH No change value = 4 Noticeable speech disturbance value = 3 Asked often to repeat words or phrases value = 2 Alternative communication methods value = 1 Unable to communicate verbally value = 0 Q1. Score =	care provider) 7. TURNING IN BED AND ADJUSTING BEDCLOTHES No change value = 4 Slower or more clumsy, without assistance value = 3 Can turn alone or adjust bed clothes value = 2 Can initiate but requires assistance value = 1 Helpless in bed value = 0 Q7. Score =
2. SALIVATION No change value = 4 Slight excess saliva, nighttime drooling value = 3 Moderately excessive saliva, minimal drooling value = 2 Marked excess of saliva, some drooling value = 1 Marked drooling, requires constant tissue value = 0 Q2. Score =	8. WALKING No change value = 4 Change in walking, no assistance or devices value = 3 Requires assistance to walk value = 2 Can move legs or stand up, unable to walk from room to room value = 1 Cannot walk or move legs value = 0 Q8. Score =
3. SWALLOWING No change value = 4 Occasional choking episodes value = 3 Modified the consistency of foods value = 2 Supplemental tube feedings value = 1 NPO (do not eat anything by mouth) value = 0 Q3. Score =	9. CLIMBING STAIRS No change value = 4 Slower value = 3 Unsteady and/or more fatigued value = 2 Requires assistance value = 1 Cannot climb stairs value = 0 Q9. Score =
4. HANDWRITING No change value = 4 Slow or sloppy, all words legible value = 3 Not all words legible value = 2 Able to hold pen, unable to write value = 1 Unable to hold pen value = 0 Q4. Score =	10. DYSPNEA No change value = 4 Occurs only with walking value = 3 Occurs with minimal exertion value = 2 Occurs at rest, either sitting or lying value = 1 Significant shortness of breath considering mechanical support value = 0 Q10. Score =
5a. CUTTING FOOD AND HANDLING UTENSILS (patients without gastrostomy) No change value = 4 Somewhat slow and clumsy, needs no help value = 3 Sometimes needs help value = 2 Foods cut by someone else value = 1 Needs to be fed value = 0 Q5a. Score =	11. ORTHOPNEA No change value = 4 Occasional shortness of breath, does not routinely use more than two pillows value = 3 Require more than 2 pillows to sleep value = 2 Can only sleep sitting up value = 1 Require the use of respiratory support (BiPAP®) to sleep value = 0 Q11. Score =
5b. CUTTING FOOD AND HANDLING UTENSILS (patients with gastrostomy) Uses PEG without assistance or difficulty value = 4 Somewhat slow and clumsy, needs no help value = 3 Requires assistance with closures and fasteners value = 2 Provides minimal assistance to caregiver value = 1 Unable to perform any manipulations value = 0 Q5b. Score =	12. RESPIRATORY INSUFFICIENCY No respiratory support value = 4 Intermittent use of BiPAP® value = 3 Continuous use of BiPAP® at night value = 2 Continuous use of BiPAP day and night value = 1 Invasive mechanical ventilation value = 0 Q12. Score =
6. DRESSING AND HYGIENE No change value = 4 Performs without assistance with increased effort or decreased efficiency value = 3 Intermittent assistance or different methods value = 2 Requires daily assistance value = 1 Completely dependent value = 0 Q6. Score =	Total Score __= / 48