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 | |
---|---|---|---|---|---|
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 of a problem has SLEEP (i.e., resting at night)
been for you
OVER THE PAST WEEK? |
How much of a problem has waking up UN- REFRESHED been for you
OVER THE PAST WEEK? |
Sleep Unref. Sleep |
||||
NO Prob |
|
Severe Prob. | NO Prob |
|
Severe Prob. |
3. Considering all the ways your Symptoms 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?
|
4. How much of a problem has Trouble Thinking or remembering
been for you OVER THE PAST WEEK?
|
Fatigue Thinking |
||||
NO Fatigue |
|
SEVERE | NO Prob |
|
SEVERE |
5. OVER THE PAST WEEK how would you rate the severity of your
body PAIN?
|
5. OVER THE PAST WEEK how much of a problem has your mood
(feeling down / anxious) affected you?
|
PAIN MOOD |
||||
NO PAIN |
|
SEVERE PAIN | NO EFFECT |
|
Worst Effect |
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 |
Jaw | |
Jaw | Jaw |
Trunk | |
Neck | Chest |
Upper Back | Abdomen |
Lower Back | Other |
Somatic Symptoms | Other Systemic Diseases | Cardiovascular Risk Assessment | ||||
Fever | Dry Eye/Dry Mouth | Loss of height / Vertebral Fracture(s) | Age > 50 years old | |||
Hair loss | Mouth ulcers | Osteoporosis | High Blood pressure | |||
Muscle pain | Easy bruising | Recent Fractures | High Cholesterol | |||
Muscle weakness | Irritable Bowel syndrome | Vitamin D deficiency | Current Smoker | |||
Chest Pain | Headache | Thyroid Disease | Ischemic Heart Disease | |||
Blurred vision | Wheezing in the chest | Parathyroid gland Disease | Stroke | |||
Hearing difficulties | Cough/ Shortness of breath | Hepatitis C | Overweight/under weight | |||
Itching | Heartburn | Diagnosed to have cancer | Diabetes Mellitus | |||
Loss of appetite | Dark or bloody stools | Absent from work due to body pains | Falls Risk Assessment | |||
Pain/cramps in the abdomen | Feeling Sickly / Nausea | Short plans for having a baby | >1 Fall in the last year | |||
Rash | Constipation | Sexual relationship Problems | Problems with your sight | |||
RaynaudŐs phenomenon | Diarrhea | Problems with erection (for men) | Loss of your balance | |||
Ringing in ears | Problems with urination | Psoriasis | Change in Gait / Walking Speed | |||
seizures | Bladder spasms | Coeliac disease | Weakness of your grip strength | |||
Sun Sensitivity | Numbness/tingling | Recent viral infection | ||||
Taste changes/Loss of taste | Problems with thinking/memory | Registered Disabled | ||||
|
|
Recent viral infection |
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 |
||
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. | |||
|
WPI: | SS (non-somatic): | SS (somatic): |
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