Name: | DoB: | ||
Hosptial Name: | Hosptial Number: | ||
Diagnosis: | Date: | ||
Current Medications: |
Over the LAST WEEK, were you able to | Without ANY Difficulty | With SOME difficulty | With MUCH Difficulty | Unable TO DO | |
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1. Get on and off the toilet? | |||||
2. Use your grip strength e.g. open previously opened Jars Or lift a saucepan during cooking? | Fn. Dis. |
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3. Dress yourself, including tying shoe laces & doing buttons? | |||||
4. Stand up from a chair without arms? | |||||
5. Wait in a line for 15 minutes? | |||||
6. Reach and get down a 5-pounds-object (such as a bag of sugar) from just above your head? | QoL |
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7. Walk outdoors on a flat ground? | |||||
8. Go Up 2 or more flights of stairs? | |||||
9. Do house work / DIY jobs around the house? | |||||
10. Move heavy objects? | |||||
Not Applicable | |||||
1. Get a good night sleep? | |||||
2. Deal with the usual stresses of daily life? | |||||
3. Cope with social/ family activities? | |||||
4. Deal with feelings of anxiety or being nervous? | |||||
5. Deal with feelings of low self esteem or feeling blue? | |||||
6. Get going in the morning? | |||||
7. Do your work as you used to do? | |||||
8. Deal with any worries about your future? | |||||
9. Continue doing things you used to do, despite tiredness? | |||||
10. Continue your relationship with your partner (husband/wife)? |
2. How much PAIN have you had because of your arthritis/ joint
or body ache OVER THE PAST WEEK?
Please select the number that best indicates your level of pain: |
Pain |
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NO PAIN |
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PAIN As Bad As It Could Be |
3. Considering all the ways your arthritis/ joint or body ache may be affecting you AT THIS TIME
Please select the number that best indicates how well you are doing: |
PGA |
|
VERY WELL |
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VERY POORLY |
4. How much of a problem has UNUSUAL FATIGUE or tiredness been
for you OVER THE PAST WEEK?
Please select the number that best indicates your fatigue |
Fatigue |
|
NO PROBLEM |
|
A MAJOR PROBLEM |
YES: | Please indicate the number of minutes , or hours until you are as limber as you will be for the day. | |
NO: |
Fever | Dry Eye | Gynecological Problem | Cardiovascular Risk Assessment | ||||||||||
Weight gain (> 10 lbs) | Dry Mouth | Short plans for having a baby | Age > 50 years old | ||||||||||
Weight Loss (> 10 lbs) | Other eye problems | Sexual Relationship Problems | High Blood pressure | ||||||||||
Loss of appetite | Headache | Problems with erection (for men) | High Cholesterol | ||||||||||
Trouble swallowing | Shortness of breath | Kidney problems | Current Smoker | ||||||||||
Soreness in the mouth | Wheezing / asthma | Absent from work due to joint pain | Ischemic Heart Disease | ||||||||||
Bleeding/inflammation of the gum | Cough | I am registered disabled | Stroke | ||||||||||
Psoriasis | Heartburn | Lost Height | Irregular Heart beats | ||||||||||
Unusual bruising or bleeding | Feeling Sickly / Nausea | Had a recent fracture | Diabetes Mellitus | ||||||||||
Neck Pain | Shoulder Blades Pain | Low Back Pain |
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Numbness or tingling | Constipation | Falls Risk Assessment | |||||||||||
Loss of hair | Diarrhea | Loss of your balance | |||||||||||
Swollen Glands | Dark or bloody stools | Problems with your sight | |||||||||||
Problems with hearing | Problems with urination | Weakness of your grip strength | |||||||||||
Thyroid Disease | Pulmonary Embolism / DVT | >1 Fall in the last year | |||||||||||
Muscle pain, ache or weakness | Diagnosed to have cancer | Change in Gait / Slow walking speed |
8. The statements below concern your personal beliefs.
Please tick the number that best describes how do you feel about the statement. 0 = Not at all; 10 = Strongly Agree |
RAI |
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1. My condition is controlling my life. | |||
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2. I would feel helpless if I could not rely on other people for help with my condition. | |||
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3. I am concerned that medicines can not help me. | |||
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4. I have concerns regarding side effects of medications used to treat my condition. | |||
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5. I often do not take my medicines as directed. | |||
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6. No matter what I do, or how hard I try, I just can not seem to get relief from my symptoms. | |||
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7. I am not coping effectively with my condition. | |||
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8. Sometimes I feel my condition is beyond both my and my doctor's control. | |||
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9. Sometimes my condition makes me feel like giving up. | |||
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10. Due to my condition, sometimes I feel I am a burden to those close to me. | |||
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RAPID 3: | DAS-28: |
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