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

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

No Pain								Severe Pain
0				50				100

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When you have completed the form, please click SUBMIT