Part A: Threshold criterion score | (1 point either) |
| ______ |
If the answer is yes to either question, proceed with test: | ______ |
Part B: Patient interview | (1 point each) |
| ______ |
| ______ |
| ______ |
| ______ |
| ______ |
| ______ |
| ______ |
| ______ |
Part C: Clinical evidence | (1 point each) |
| ______ |
| ______ |
Total score | ______ |