EL Miedany e-PROMs

Patient Reported Outcome Measures for Spondyloarthritis (AS, Psoriasis, IBD)

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. Drink from a glass?
2. Dress yourself, including tying shoelaces & putting on socks					Fn. Dis.
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
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
NO PAIN	0 1 2 3 4 5 6 7 8 9 10	PAIN As Bad As It Could Be	NO PAIN	0 1 2 3 4 5 6 7 8 9 10	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	0 1 2 3 4 5 6 7 8 9 10	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 1 2 3 4 5 6 7 8 9 10	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
NO STIFFNESS	0 1 2 3 4 5 6 7 8 9 10	SEVERE STIFFNESS	0 Min	0 30 60 90 > 2 Hrs	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	0 1 2 3 4 5 6 7 8 9 10	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	0 1 2 3 4 5 6 7 8 9 10	Severe Rash

6_A. Please tick in the appropriate box to indicate in which of your joints you feel painful/swollen TODAY.

Painful Joints:

Swollen Joints:

6_B. Please tick in the appropriate box to indicate in which of your joints you feel painful/swollen TODAY.

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

7. Please tick (✓) if you have experienced any of the following OVER THE LAST 10-days:

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



ESR:	CRP:
HLA-B27: Positive Negative
Cholestrol:	Total Chol:HDL
B/P:	BMI:

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
1. My condition is controlling my life.
0 1 2 3 4 5 6 7 8 9 10
2. I would feel helpless if I could not rely on other people for help with my condition.
0 1 2 3 4 5 6 7 8 9 10
3. I am concerned that medicines can not help me.
0 1 2 3 4 5 6 7 8 9 10
4. I have concerns regarding side effects of medications used to treat my condition.
0 1 2 3 4 5 6 7 8 9 10
5. I often do not take my medicines as directed.
0 1 2 3 4 5 6 7 8 9 10
6. No matter what I do, or how hard I try, I just can not seem to get relief from my symptoms.
0 1 2 3 4 5 6 7 8 9 10
7. I am not coping effectively with my condition.
0 1 2 3 4 5 6 7 8 9 10
8. Sometimes I feel my condition is beyond both my and my doctor's control.
0 1 2 3 4 5 6 7 8 9 10
9. Sometimes my condition makes me feel like giving up.
0 1 2 3 4 5 6 7 8 9 10
10. Due to my condition, sometimes I feel I am a burden to those close to me.
0 1 2 3 4 5 6 7 8 9 10

RAPID 3: ASDAS-CRP: ASDAS-ESR:

Patent Pending. Patent Registration No. 1511756.7
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Patient Reported Outcome Measures for Spondyloarthritis (AS, Psoriasis, IBD)

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.

Painful Joints:

Swollen Joints: