1. Please check (√) the one best answer for your abilities at this time: With With UNABLE OVER THE LAST WEEK, were you able to: SOME MUCH To Do Diffculty Diffculty a. Dress yourself, including tying shoelaces and doing buttons? 1 2 3 b. Get in and out of bed? 1 2 3 c. Lift a full cup or glass to your mouth? 1 2 3 d. Walk outdoors on fat ground? 1 2 3 e. Wash and dry your entire body? 1 2 3 f. Bend down to pick up clothing from the foor? 1 2 3 g. Turn regular faucets on and off? 1 2 3 h. Get in and out of a car, bus, train, or airplane? 1 2 3 i. Walk two miles or three kilometers, if you wish? 1 2 3 j. Participate in recreational activities and sports as you would like, 1 2 3 if you wish? k. Get a good night’s sleep? 1.1 2.2 3.3 l. Deal with feelings of anxiety or being nervous? 1.1 2.2 3.3 m. Deal with feelings of depression or feeling blue? 1.1 2.2 3.3 2. How much pain have you had because of your condition OVER THE PAST WEEK? please indicate below how severe your pain has been: NO PAIN AS BAD AS PAIN 0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 IT COULD BE 3. Please place a check (√) in the appropriate spot to indicate the amount of pain you are having today in each of the joint areas listed below: a. LEFT FINGERS i. RIGHT FINGERS b. LEFT WRIST j. RIGHT WRIST c. LEFT ELBOW k. RIGHT ELBOW d. LEFT SHOULDER l. RIGHT SHOULDER e. LEFT HIP m. RIGHT HIP f. LEFT KNEE n. RIGHT KNEE g. LEFT ANKLE o. RIGHT ANKLE h. LEFT TOES p. RIGHT TOES q. NECK r. BACK 4. Considering all the ways in which illness and health conditions may afect you at this time, please indicate below how you are doing: VERY VERY WELL 0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 POORLY Without ANY Diffculty 0 0 0 0 0 0 0 0 0 0 0 0 0 None 0 0 0 0 0 0 0 0 0 None 0 0 0 0 0 0 0 0 0 Mild 1 1 1 1 1 1 1 1 1 Mild 1 1 1 1 1 1 1 1 1 Moderate 2 2 2 2 2 2 2 2 2 Moderate 2 2 2 2 2 2 2 2 2 Severe 3 3 3 3 3 3 3 3 3 Severe 3 3 3 3 3 3 3 3 3 Ref: Pincus T. The Journal of Rheumatology 2008; 35:11 6
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