Multi-Dimensional Patient Reported Outcome Measures-SLE
This questionnaire includes information not available from blood tests, X-rays, or any source other than you. Please try to answer each question. There is no right or wrong answer. Please answer exactly as YOU think or feel.
| Name: | DoB: | ||
| Hosptial Name: | Hosptial Number: | ||
| Diagnosis: | Date: | ||
| Current Medications: | |||
- 1. We are interested in learning how your illness affects your ability to function in daily life. Please tick () the ONE best answer that describes your usual abilities OVER THE PAST WEEK:
Over the LAST WEEK, were you able to Without ANY Difficulty With SOME difficulty With MUCH Difficulty Unable TO DO 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.
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
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 Lupus disease OVER THE PAST WEEK?
Please select the number that best indicates your level of pain:
Pain
NO PAIN - 0
- 10
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- 70
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- 100
PAIN As Bad As It Could Be -
3. Considering all the ways Lupus may be affecting you AT THIS TIME
Please select the number that best indicates how well you are doing:
PGA
VERY WELL - 0
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- 100
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 - 0
- 10
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- 60
- 70
- 80
- 90
- 100
A MAJOR PROBLEM -
5. OVER THE LAST WEEK when you awakened in the morning, did you feel stiff?
YES: Please indicate the number of minutes , or hours until you are as limber as you will be for the day. NO: -
6. Please tick in the appropriate box to indicate in which of your joints you feel painful/swollen TODAY.
Painful Joints:
Swollen Joints:
- 7. Please tick (✓) if you have experienced any of the following OVER THE LAST 10-days:
Fits / seizures Tender finger nodules Gynecological Problem Cardiovascular Risk Assessment Hallucinations Muscle pain Short plans for having a baby Age > 50 years old Illogical thinking Muscle weakness Miscarriage High Blood pressure Bizarre/disorganized behavior New/recurrent skin rash Sexual Relationship Problems High Cholesterol Difficulty to focus Patchy or diffuse loss of hair Problems with passing water Current Smoker Altered speech Mouth ulcers Dark/ reddish urine/ Kidney Problem Ischemic Heart Disease Insomnia Wheezing / asthma I worry about my appearance Stroke Daytime drowsiness Cough / shortness of breath Lost Height History of DVT/Vasculitis Visual disturbance Chest pain Had a recent fracture Diabetes Mellitus Double vision/ squint Feeling Sickly / Nausea Falls Risk Assessment ESR: CRP: Anti-CCP titer: RF titer: Cholestrol: Total Chol:HDL B/P: BMI: Change in the look of your face Dry Eye Loss of your balance Problems with hearing Dry Mouth Problems with your sight Persistent headache Fever Weakness of your grip strength Migraine Pulmonary Embolism / DVT >1 Fall in the last year Finger ulcers/gangrene/dark spots Diagnosed to have cancer Change in Gait / Slow walking speed Cast in the urine More than 0.5 gram of protin/24HR More than 5 red blood cells in the urine More than 5 white cells in the urine Low complement 3 Low platelet<100.000/mm3 Low complement 4 White cell count<3000 -
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. - 0
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- 10
2. I would feel helpless if I could not rely on other people for help with my condition. - 0
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- 10
3. I am concerned that medicines can not help me. - 0
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- 10
4. I have concerns regarding side effects of medications used to treat my condition. - 0
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- 10
5. I often do not take my medicines as directed. - 0
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- 10
6. No matter what I do, or how hard I try, I just can not seem to get relief from my symptoms. - 0
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7. I am not coping effectively with my condition. - 0
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8. Sometimes I feel my condition is beyond both my and my doctor's control. - 0
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9. Sometimes my condition makes me feel like giving up. - 0
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10. Due to my condition, sometimes I feel I am a burden to those close to me. - 0
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- 10
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RAPID 3: SLEDAI:
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