How Does Your Rheumatoid Arthritis Affect You?

Your Name:
Your Birthdate:

Please check the response that best describes your usual abilities over the past week.

Without
ANY
difficulty
(0)
With
SOME
difficulty
(1)
With
MUCH
difficulty
(2)

Unable
to do
(3)
DRESSING & GROOMING - are you able to:
Dress yourself, including showlaces and buttons?
Shampoo your hair?

ARISING - are you able to:
Standup from a straight chair?
Get in and out of bed?

EATING - are you able to:
Cut your meat?
Lift a full cup or glass to your mouth?
Open a new milk carton?

WALKING - are you able to:
Walk outdoors on flat ground?
Climb up 5 steps?



Please check any AIDS or DEVICES that you usually use for any of the above activities:
Devices used for dressing (button hook, zipper pull, etc.) Built-up or special utensils
Crutches Cane Wheelchair
Special or built-up chair Walker


Please check any categories for which you usually need HELP FROM ANOTHER PERSON:
Dressing and Grooming Arising
Walking Eating



Without
ANY
difficulty
(0)
With
SOME
difficulty
(1)
With
MUCH
difficulty
(2)

Unable
to do
(3)
HYGIENE - are you able to:
Wash and dry your body?
Take a tub bath?
Get on adn off the toilet?

REACH - are you able to:
Reach and get down a 5 pound object
(such as a bag of sugar) from above your head?
Bend down to pick up clothing from the floor?

GRIP - are you able to:
Open car doors?
Open previously opened jars?
Turn faucets on and off?

ACTIVITIES - are you able to:
Run errands and shop?
Get in and out of a car?
Do chores such as vacuuming or yard work?



Please check any AIDS or DEVICES that you usually use for any of the above activities:
Raised toilet seat Long-handled appliances for reach
Bathtub bar Long-handled appliances in bathroom
Bathtub seat Jar opener (for jars previously opened)


Please check any categories for which you usually need HELP FROM ANOTHER PERSON:
Hygiene Reach
Errands and chores Gripping and opening things



How much pain have you had from your illness IN THE PAST WEEK:

No
Pain
Severe
Pain
0 50 100



When you have completed the form, please click SUBMIT

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