AMS Worksheet

Based on the Lake Louise AMS Questionnaire

Name______________________________    Age ____   Sex____  Date _____________

Prev Hx AMS/HAPE/HACE?
Meds:

Ascent Profile:
Treatment:


                                        Time   ____  ____  ____  ____  ____
                                    Altitude   ____  ____  ____  ____  ____
Symptoms:
1.Headache:
                               No headache 0   ____  ____  ____  ____  ____
                             Mild headache 1   ____  ____  ____  ____  ____
                         Moderate headache 2   ____  ____  ____  ____  ____
                    Severe, incapacitating 3   ____  ____  ____  ____  ____
2.GI:
                            No GI symptoms 0   ____  ____  ____  ____  ____
                   Poor appetite or nausea 1   ____  ____  ____  ____  ____
               Moderate nausea or vomiting 2   ____  ____  ____  ____  ____
                Severe N&V, incapacitating 3   ____  ____  ____  ____  ____
3.Fatigue/weak:
                         Not tired or weak 0   ____  ____  ____  ____  ____
                     Mild fatigue/weakness 1   ____  ____  ____  ____  ____
                 Moderate fatigue/weakness 2   ____  ____  ____  ____  ____
                Severe F/W, incapacitating 3   ____  ____  ____  ____  ____
4.Dizzy/lightheaded:
                                 Not dizzy 0   ____  ____  ____  ____  ____
                            Mild dizziness 1   ____  ____  ____  ____  ____
                        Moderate dizziness 2   ____  ____  ____  ____  ____
                    Severe, incapacitating 3   ____  ____  ____  ____  ____
5.Difficulty sleeping:
                       Slept well as usual 0   ____  ____  ____  ____  ____
            Did not sleep as well as usual 1   ____  ____  ____  ____  ____
       Woke many times, poor night's sleep 2   ____  ____  ____  ____  ____
                    Could not sleep at all 3   ____  ____  ____  ____  ____
Symptom Score:
                                               ____  ____  ____  ____  ____

Clinical Assessment:
6.Change in mental status:
                                 No change 0   ____  ____  ____  ____  ____
                        Lethargy/lassitude 1   ____  ____  ____  ____  ____
                      Disoriented/confused 2   ____  ____  ____  ____  ____
                  Stupor/semiconsciousness 3   ____  ____  ____  ____  ____
7.Ataxia(heel to toe walking):
                                 No ataxia 0   ____  ____  ____  ____  ____
             Maneuvers to maintain balance 1   ____  ____  ____  ____  ____
                            Steps off line 2   ____  ____  ____  ____  ____
                                Falls down 3   ____  ____  ____  ____  ____
                               Can't stand 4   ____  ____  ____  ____  ____
8.Peripheral edema:
                                  No edema 0   ____  ____  ____  ____  ____
                              One location 1   ____  ____  ____  ____  ____
                     Two or more locations 2   ____  ____  ____  ____  ____
Clinical Assessment Score:
                                               ____  ____  ____  ____  ____
Total Score:
                                               ____  ____  ____  ____  ____


Using the worksheet

Patients are assigned a single score for each numbered group. For visual ease, we have designed the worksheet so that this score is entered next to the corresponding symptom severity level.

For example, a person with moderate AMS might get 2 points for moderate headache, 1 point for poor appetite, and 1 point for mild fatigue, for a total symptom score of 4. In addition, this person might get 1 point for facial edema, for a clinical assessment score of 1 and a total AMS score of 5.

Serial evaluations several hours apart give a good measure of whether a patient is responding to treatment or deteriorating.

(This page looks best printed in a fixed-width font)

Also see the
AMS worksheet with phonetic Nepali translations


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Copyright© Thomas E. Dietz, MD
Emergency & Wilderness Medicine

This Page URL: http://www.high-altitude-medicine.com/AMS-worksheet.html
Last modified 8-May-2000