Date: | ||||
Patient name: | ||||
Mark each box that applies | Item score (female) | Item score (male) | ||
|
| [ ] | 1 | 3 |
| [ ] | 2 | 3 | |
| [ ] | 4 | 4 | |
|
| [ ] | 3 | 3 |
| [ ] | 4 | 4 | |
| [ ] | 5 | 5 | |
| [ ] | 1 | 1 | |
| [ ] | 3 | 0 | |
|
| [ ] | 2 | 2 |
| [ ] | 1 | 1 | |
TOTAL: | _____ | _____ | ||
Total score risk category:
|
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