Ankylosing Spondylitis Form

Fields marked with an asterisk (*) are required.

Part 1 - Personal Details

Current Medication

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...

Arising

Over the past week...

Eating

Over the past week...

Walking

Over the past week...

Hygiene

Over the past week...

Reach

Over the past week...

Grip

Over the past week...

Activities

Over the past week...
Please check any aids or devices that you usually use for any of these activities
Please check any categories for which you need help from another person.
List aids and devices you usually use for any of these activities.

Compared to 6 months ago, is your ability to manage aspects of daily life

Function is...