Duchenne Muscular Dystrophy Assessment
Please complete this form to help assess the current status and abilities related to Duchenne Muscular Dystrophy.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Diagnosis Confirmation
*
Confirmed Duchenne Muscular Dystrophy
Suspected
Other (please specify below)
Mobility Assessment
*
Rows
Independent
With Assistance
Unable
Walking
1
2
3
Climbing stairs
4
5
6
Standing from sitting
7
8
9
Rising from floor
10
11
12
Upper Limb Function
*
Rows
Performs easily
Performs with difficulty
Unable
Feeding self
13
14
15
Brushing teeth
16
17
18
Lifting arms overhead
19
20
21
Respiratory Status
*
No difficulties
Occasional shortness of breath
Requires ventilatory support
Cardiac Status
No known issues
Under cardiac monitoring
On cardiac medication
Current Medications
Functional Rating (1 = Unable, 5 = No difficulty)
Unable
1
2
3
4
No difficulty
5
1 is Unable, 5 is No difficulty
Additional Comments or Observations
Submit Assessment
Should be Empty: