Follow Up Form

Fields marked with an asterisk (*) are required.

Part 1 - Personal Details

Follow up information for all patients

Please complete the form - it includes important information which helps us offer the best care. Please try to answer each question, even if you do not think it is related to you at this time. There are no right or wrong answers. Please answer exactly as you think or feel. Please check the ONE best answer for your abilities OVER THE PAST WEEK:

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...

How long does early morning stiffness last? (mins)

How do you rate your pain on a scale of 10 (in the last 7 days)? 0 is no pain, 10 is the worst pain you can imagine.
0
How do you rate your fatigue on a scale of 10 (in the last 7 days)? 0 is no fatigue, 10 is the worst fatigue you can imagine.
0
How active has your arthritis been in the LAST 24 HOURS? Zero is NOT active, 10 is the most active it could ever be.
0
Medication changes