Sunnyside Clinic
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Ankylosing Spondylitis Form
Fields marked with an asterisk (
*
) are required.
Part 1 - Personal Details
First Name
*
Middle Initial
Last Name
*
Date of Birth
*
Day of Birth
*
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Month of Birth
*
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
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Oct
Nov
Dec
Year of Birth
*
1922
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2022
Age
*
Gender
*
Male
Female
Email
Current Medication
Are you currently taking medication for your AS?
Yes
No
Please indicate the effectiveness of the medication in relieving your symptoms. (1 is not effective, 10 is very effective)
0
Pain on a ten point scale (1 is none and 10 is the worst)
Please indicate your level of ability with each of the following activities during the
past week
.
How would you describe the overall level of fatigue/tiredness you have experienced?
0
How would you describe the overall level of AS neck, back or hip pain you have had?
0
How would you describe the overall level of pain/swelling in joints other than neck, back or hips you have had?
0
How would you describe the overall level of discomfort you have had from any areas tender to touch or pressure?
0
How would you describe the overall level of discomfort you have had from the time you wake up?
0
How long (in minutes) does your morning stiffness last from the time you wake up? (0 is no stiffness, 120 is 2+ Hours)
0
Additional comments
Health Assessment Questionnaire
The following questions are part of a validated questionnaire to collect information about daily function. Even if you think you are normal we need to know - as it is important for us to know how all of our patients function from day to day.
Dressing and Grooming
Over the past week...
Were you able to dress yourself, including tying shoelaces and doing buttons?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Shampoo your hair?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Arising
Over the past week...
Were you able to stand up from an armless chair?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Were you able to get in and out of bed?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Eating
Over the past week...
Were you able to cut your meat?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Were you able to lift a full cup or glass to your mouth?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Were you able to open a new milk carton?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Walking
Over the past week...
Were you able to walk outdoors on flat ground?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Were you able to climb up five steps?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Hygiene
Over the past week...
Were you able to wash and dry your entire body?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Were you able to take a tub bath?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Were you able to get on and off the toilet?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Reach
Over the past week...
Were you able to reach and get a 5lb object (e.g. bag of sugar) from just above your head?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Were you able to bend down and pick up clothing from the floor?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Grip
Over the past week...
Were you able to open car doors?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Were you able to open jars which have been previously opened?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Were you able to turn faucets on and off?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Activities
Over the past week...
Were you able to run errands and shop?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Were you able to get in and out of a car?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Were you able to do chores such as vacuuming, yard work?
No difficulty
Mild difficulty
Moderate difficulty
Unable
Please check any aids or devices that you usually use for any of these activities
Cane
Walker
Crutches
Wheelchair
Devices used for dressing, e.g. button hook
Built-up or special utensils
Special or built-up chair
Other
Please check any categories for which you need help from another person.
Dressing and grooming
Eating
Arising
Walking
List aids and devices you usually use for any of these activities.
Raised toilet seat
Bathtub seat
Bathtub bar
Long handled appliance in bathroom
Long handled appliance for reach
Jar opener
Hygiene
Errands and chores
Gripping and opening things
Compared to 6 months ago, is your ability to manage aspects of daily life
Function is...
Better
Same
Worse
How long (in minutes) does your morning stiffness last from the time you wake up? (0 is no stiffness, 120 is 2+ Hours)
0
Send me a copy of this completed form
Send me a copy of this completed form
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