Medical Record Verification Form

Attachment 4

Instructions for Completing the Medical Record Verification Form

Please complete the form attached for each participant selected by looking at the 1^st and the last neurology note. If you are unable to complete the form with just two notes, please review the rest of the record. Each question should be answered. For questions that have multiple subquestions, such as muscle atrophy, please continue reviewing the medical record until you can answer at least one of the subquestions (tongue, upper extremity, lower extremity, or unspecified location).

ATSDR AMYOTROPHIC LATERAL SCLEROSIS MEDICAL RECORD VERIFICATION FORM

1. Difficulty swallowing (dysphagia) (at any time): Yes No or not noted

2. Difficulty talking (dysarthria) (at any time): Yes No or not noted

3. Limb weakness (at any time):

A. Upper extremity Yes No or not noted

B. Lower extremity Yes No or not noted

C. Generalized Yes No or not noted

4. Hyper-active Reflexes (at any time)

   1. Upper extremity (Biceps, Brachioradialis or Triceps)

Yes No or not noted

B. Lower extremity (Knee jerk, ankle jerk or positive Babinski response)

Yes No or not noted

5. Fasciculations (at any time)

   1. Tongue Yes No or not noted

   2. Upper extremity Yes No or not noted

   3. Lower extremity Yes No or not noted

   4. Chest Yes No or not noted

   5. Unspecified location Yes No or not noted

6. Muscle atrophy (at any time)

   1. Tongue Yes No or not noted

   2. Upper extremity Yes No or not noted

   3. Lower extremity Yes No or not noted

   4. Unspecified location Yes No or not noted

7. Site of Onset of Weakness (initial visit only, check one):

Bulbar Truncal Generalized Respiratory

Limb Upper Limb Lower None Unknown

8. Ever treated with riluzole (at any time):

Yes No

9. Date of Death (if applicable and known):       /       (mm/yyyy) NA Don’t know

10. Please attach a copy of the most recent EMG report to this abstraction form.

Yes, attached No, not available