The history questionnaire is self-administered by the patient. Responses are added to
obtain the total score. Responses of “yes” to items 1-3, 5-6, 8-9, 11-12, 14-15 are each
counted as one point. A “no” response on items 7 and 13 counts as 1 point. Item #4 is a
measure of impaired circulation and item #10 is a measure of general aesthenia and are
not included in scoring. To decrease the potential for bias, all scoring information has
been eliminated from the patient version.