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. Drink from a glass? | |||||
2. Dress yourself, including tying shoelaces & putting on socks | Fn. Dis. |
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3. Bend down to pick up object off the floor | |||||
4. Sit for long periods of time e.g. working on flat topped table or desk | |||||
5. Walk outdoors on flat ground including crossing the road | |||||
6. Go up 2 or more flights of stairs | QoL |
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7. Play with / look after children | |||||
8. Do outside work (such as DIY/ gardening/ lifting) | |||||
9. Lie down / sleep on your back | |||||
10. Turn your head whilst reversing your car or use the rear view mirror? | |||||
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 SPINE PAIN have you had OVER THE PAST WEEK?
Please select the number that best indicates your level of pain: |
2. How much JOINT PAIN have you had OVER THE PAST WEEK?
Please select the number that best indicates your level of pain: |
SP. Pain J. Pain |
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NO PAIN |
|
PAIN As Bad As It Could Be | NO PAIN |
|
PAIN As Bad As It Could Be |
3. Considering all the ways your Disease may be affecting you
AT THIS TIME
Please select the number that best indicates how well you are doing: |
PGA |
|
VERY WELL |
|
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 |
5. OVER THE PAST WEEK how would you rate the severity of your
morning stiffness?
Please select the number that best indicates your fatigue |
5. OVER THE PAST WEEK for how long (min./hours) did you feel
stiff in the morning?
|
MS VAS MS MINs |
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NO STIFFNESS |
|
SEVERE STIFFNESS | 0 Min |
|
More than 2 Hrs |
Over the Past Week, how much has your skin problem affected your life (felt embarrassed, influenced the clothes you wear,
affected you doing a sport, caused problems with your partner or friends.
|
Ps. Sev. |
|
Not at All |
|
Very Much |
How would you rate the severity of your psoriatic skin rash Over the Past Week:
Skip if you don't have Psoriasis |
Ps. Qol. |
|
No Rash |
|
Severe Rash |
Right | Left |
Upper Limb | |
Tip of the Shoulder | Tip of the Shoulder |
Outer side of the Arm | Outer side of the Arm |
Outer/ inner side of the elbow | Outer/ inner side of the elbow |
Lower Limb | |
Outer Hip Area | Outer Hip Area |
Front of the knee | Front of the knee |
Back of the ankle | Back of the ankle |
Heel | Heel |
Jaw | |
Jaw | Jaw |
Trunk | |
Neck | Chest |
Upper Back | Abdomen |
Lower Back | Other |
Fever | Dry Eye | Vertebral Fracture(s) | Cardiovascular Risk Assessment | ||||||||||
Weight gain (> 10 lbs) | Dry Mouth | Weakness/Paralysis of arms or legs | Age > 50 years old | ||||||||||
Weight Loss (> 10 lbs) | Pain in the eye / photophobia | Numbness or tingling | High Blood pressure | ||||||||||
Night Sweat | Headache | Muscle pain, ache or cramps | High Cholesterol | ||||||||||
Loss of appetite | Wheezing in the chest | Problems with thinking/memory | Current Smoker | ||||||||||
Soreness in the mouth | Cough | Absent from work due to spine pain | Ischemic Heart Disease | ||||||||||
Genital Ulcers | Blood in your Phlegm | Short plans for having a baby | Stroke | ||||||||||
Skin Rash | Shortness of breath | Sexual relationship Problems | Irregular Heart Beats | ||||||||||
Psoriasis | Heartburn | Problems with erection (for men) | Diabetes Mellitus | ||||||||||
Painful Swollen finger/ toe | Dark or bloody stools | Falls Risk Assessment |
|
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Change color/ thickening of your nail | Feeling Sickly / Nausea | >1 Fall in the last year | |||||||||||
Inflammatory bowel Disease | Constipation | Problems with your sight | |||||||||||
Heart Valve lesion | Diarrhea | Loss of your balance | |||||||||||
Problems with hearing | Problems with urination | Change in Gait / Walking Speed | |||||||||||
Ringing in the ears | > 3 Alcoholic drinks per day | Weakness of your grip strength |
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: | ASDAS-CRP: | ASDAS-ESR: |
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