Addition of the selected points:

Organ System	Variable	Points
Heart	No problem	0
	MI >5 years ago, occasional angina treated with meds as needed	1
	CHF compensated with meds, daily antianginal meds, left ventricular hypertrophy, atrial fibrillation, bundle branch block, daily antiarrhythmic drugs	2
	MI ≤5 years ago, abnormal stress test, past PTCA or CABG	3
	Marked activity restriction secondary to cardiac status (i.e., unstable angina or intractable CHF)	4
Vascular	No problem	0
	Hypertension compensated with salt restriction and weight loss, cholesterol >200 mg/dL	1
	Daily antihypertensive meds, one symptom of atherosclerotic disease (angina, claudication, bruit, amaurosis fugax, absent pedal pulses), aortic aneurysm <4 cm	2
	≥2 symptoms of atherosclerosis	3
	Previous vascular surgery, aortic aneurysm ≥4 cm	4
Hematopoietic	No problem	0
	Hemoglobin: females 10-12 g/dL, males 12-14 g/dL, anemia of chronic disease	1
	Hemoglobin: females 8 to <10 g/dL, males 10 to <12 g/dL, anemia secondary to iron/vitamin B-12/folate deficiency or chronic renal failure, total WBC 2,000-4,000	2
	Hemoglobin: females <8 g/dL, males <10 g/dL, total WBC <2,000	3
	Any leukemia or lymphoma	4
Respiratory	No problem	0
	Recurrent episodes of acute bronchitis, current treated asthma with inhalers as needed, cigarette smoker 10-20 pack years	1
	X-ray evidence of COPD, requires daily theophylline or inhalers, treated for pneumonia two or more times in the past 5 years, smoked 21-40 pack years	2
	Limited ambulation secondary to limited respiratory capacity, requires oral steroids for lung disease, smoked >40 pack years	3
	Requires supplemental oxygen, ≥1 episode of respiratory failure requiring assisted ventilation, any lung cancer	4
Eyes, ears, nose, throat, and larynx	No problem	0
	Corrected vision 20/40, chronic sinusitis, mild hearing loss	1
	Corrected vision 20/60 or reads newsprint with difficulty, requires hearing aid, chronic sinonasal complaints requiring medication, requires medication for vertigo	2
	Partially blind (requires an escort to venture out), unable to read newsprint, conversational hearing still impaired with hearing aid	3
	Functional blindness, functional deafness, laryngectomy, requires surgical intervention for vertigo	4
Upper GI	No problem	0
	Hiatal hernia, heartburn complaints treated with as-needed meds	1
	Needs daily H₂ blocker or antacid, documented gastric or duodenal ulcer within 5 years	2
	Active ulcer, guaiac positive stools, any swallowing disorder or dysphagia	3
	Gastric cancer, history of perforated ulcer, melena or hematochezia from upper GI source	4
Lower GI	No problem	0
	Constipation managed with meds as needed, active hemorrhoids, status post hernia repair	1
	Requires daily bulk laxatives or stool softeners, diverticulosis, untreated hernia	2
	Bowel impaction in the past year, daily use of stimulant laxatives or enemas	3
	Hematochezia from lower GI source, currently impacted, diverticulitis flare up, status post bowel obstruction, bowel carcinoma	4
Liver, pancreas, and biliary	No problem	0
	History of hepatitis >5 years ago, cholecystectomy	1
	Mildly elevated LFTs (≤150% of normal), hepatitis within 5 years, cholelithiasis, daily or heavy alcohol use within 5 years	2
	Elevated bilirubin (total >2 mg/dL), marked elevation of LFTs (>150% of normal), requires supplemental pancreatic enzymes for digestion	3
	Clinical or lab evidence of biliary obstruction, any biliary tree carcinoma, cholecystitis, pancreatitis, active hepatitis	4
Renal	No problem	0
	Kidney stone passage within the past 10 years or asymptomatic kidney stone, pyelonephritis within 5 years	1
	Serum creatinine 1.5-3.0 mg/dL without diuretic or antihypertensive medication	2
	Serum creatinine >3.0 mg/dL OR serum creatinine >1.5 mg/dL on diuretic, antihypertensive, or bicarbonate therapy, current pyelonephritis	3
	Requires dialysis, renal carcinoma	4
Genitourinary	No problem	0
	Stress incontinence, hysterectomy, BPH without urinary symptoms	1
	Abnormal pap smear, frequent UTIs (≥3 in past year), urinary incontinence (non-stress) in females, BPH with hesitancy or frequency, current UTI, any urinary diversion procedure, status post TURP	2
	Prostate cancer in situ (i.e., found incidently during TURP), vaginal bleeding, cervical carcinoma in situ, hematuria, status post urosepsis in past year	3
	Acute urinary retention, any GU carcinoma except as above	4
Musculoskeletal and skin	No problem	0
	Uses meds as needed for arthritis or has mildly limited activities of daily living (ADLs) from joint pathology, excised non-melanoma skin cancers, skin infections requiring antibiotics within a year	1
	Daily antiarthritic meds or use of assistive devices or moderate limitation in ADLs, daily meds for chronic skin conditions, melanoma without metastasis	2
	Severely impaired ADLs secondary to arthritis, requires steroids for arthritic condition, vertebral compression fractures from osteoporosis	3
	Wheelchair bound, severe joint deformity or severely impaired usage, osteomyelitis, any bone or muscle carcinoma, metastatic melanoma	4
Neurologic	No problem	0
	Frequent headaches requiring meds as needed without interference with daily activities, history of TIA phenomena (at least one)	1
	Requires daily meds for chronic headaches or headaches that regularly interfere with daily activities, status post CVA without significant residual, mild neurodegenerative disease (Parkinson's, MS, ALS, etc)	2
	Status post CVA with mild residual dysfunction, any CNS neurosurgical procedure, moderate neurodegenerative disease	3
	Status post CVA with residual functional hemiparesis or aphasia, severe neurodegenerative disease	4
Endocrine and breast	No problem	0
	Diabetes mellitus compensated with diet, obesity (BMI >30), requires thyroid hormone replacement	1
	Diabetes mellitus requiring insulin or oral agents, fibrocystic breast disease	2
	Any electrolyte disturbance requiring hospital treatment, morbid obesity (BMI >45)	3
	Brittle or poorly controlled diabetes mellitus or diabetic coma in the past year, requires adrenal hormone replacement, adrenal, thyroid, or breast carcinoma	4
Psychiatric illness	No problem	0
	Minor psychiatric condition or history thereof: specifically, previous outpatient mental health treatment during a crisis, outpatient treatment for depression >10 years ago, current use of minor tranquilizers for episodic anxiety (occasional usage), mild early dementia	1
	A history of major depression (by DSM*) within the past 10 years (treated or untreated), mild dementia, any previous psychiatric hospitalization, any psychotic episode substance abuse history >10 years ago	2
	Currently meets DSM* criteria for major depression or two or more episodes of major depression in the past 10 years, moderate dementia, current usage of daily anti-anxiety medication, currently meets DSM* criteria for substance abuse or dependency, requires daily antipsychotic medication	3
	Current mental illness requiring psychiatric hospitalization, institutionalization, or intensive outpatient management (e.g. patients with severe or suicidal depression, acute psychosis or psychotic decompensation, severe agitation from dementia, severe substance abuse, etc), severe dementia	4

*Original study references DSM III-R.

Cumulative Illness Rating Scale-Geriatric (CIRS-G)