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/weakness:
                               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 as 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 (Symptom + Clinical):               ____ ____ ____ ____ ____

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.

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