Score: Comments:

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1.	Age in Years	Select One Under 44 45-54 55-64 65-74 Over74
2.	History of severe organ insufficiency or immunocompromised?	Select One Yes, and non-operative or emergency post-operative patient Yes, and elective post-operative patient. No
3.	Rectal Temperature (Celsius)	Select One over 40.9 39-40.9 38.5-38.9 36-38.4 34-35.9 32-33.9 30-31.9 below 30
4.	Mean arterial pressure (mmHg)	Select One over 159 130-159 110-129 70-109 50-69 below 50
5.	Heart rate (ventricular response)	Select One over 179 140-179 110-139 70-109 55-69 40-54 below 40
6.	Respiratory Rate (non-ventilated or ventilated)	Select One over 49 35-49 25-34 12-24 10-11 6-9 below 6
7.	Oxygenation (use PaO2 if FiO2 < 50%, otherwise use A-a gradient)	Select One A-a gradient over 499 A-a gradient 350-499 A-a gradient 200-349 A-a below 200(if FiO2 over 49%) or pO2 more than 70 (if FiO2 less than 50%) pO2 = 61-70 pO2 = 55-60 pO2 below 55
8.	Arterial pH	Select One over 7.69 7.60-7.69 7.50-7.59 7.33-7.49 7.25-7.32 7.15-7.24 below 7.15
9.	Serum sodium (mMol/L)	Select One over 179 160-179 155-159 150-154 130-149 120-129 111-119 below 111
10.	Serum potassium (mMol/L)	Select One over 6.9 6-6.9 5.5-5.9 3.5-5.4 3-3.4 2.5-2.9 below 2.5
11.	Serum Creatinine (mg/100 mL)	Select One over 3.4 and ACUTE renal failure 2.0-3.4 and ACUTE renal failure over 3.4 and chronic 1.5-1.9 and ACUTE renal failure 2.0-3.4 and chronic 1.5-1.9 and chronic 0.6-1.4 below 0.6
12.	Hematocrit (%)	Select One over 59.9 50-59.9 46-49.9 30-45.9 20-29.9 below 20
13.	White blood count (total/cubic mm in 1000's)	Select One over 39.9 20-39.9 15-19.9 3.0-14.9 1.0-2.9 below 1.0