Rheumatoid Arthritis - Follow-up Form
The scale below is used to assess rheumatoid arthritis symptoms. This form can help your physician effectively target problems you may be experiencing. By completing the form on a regular basis,
it can also be used to determine the effectiveness of treatment. Answer all the questions as they pertain to the last 7 days.
Date: ________________________
Symptoms |
Pain |
Pain intensity |
No pain |
0 1 2 3 4 5 6 7
8 9 10 |
Extreme pain |
|
|
|
Fatigue |
State of fatigue |
No fatigue |
0 1 2 3 4 5 6 7
8 9 10 |
Extreme fatigue |
|
|
|
Stiffness |
Morning stiffness |
No stiffness |
0 1 2 3 4 5 6 7
8 9 10 |
Extreme stiffness |
|
Lasts on average |
__________h __________min |
|
|
Overall assessment of the last week |
Taking all symptoms into consideration, this week has been: |
Great |
0 1 2 3 4 5 6 7
8 9 10 |
Extremely difficult |
|
|
|
Location of pain |
Check the boxes that correspond to where you have joint pain. |
 |
|
|
Activities |
In this section, tell us whether you were able to perform the activities listed below, and rate their degree of difficulty. |
0: Easy 1: Somewhat difficult 2: Very difficult 3: Not possible |
Stand in line for 15 minutes |
☐ 0 |
☐ 1 |
☐ 2 |
☐ 3 |
Move a heavy object |
☐ 0 |
☐ 1 |
☐ 2 |
☐ 3 |
Do housecleaning |
☐ 0 |
☐ 1 |
☐ 2 |
☐ 3 |
Carry out daily tasks |
☐ 0 |
☐ 1 |
☐ 2 |
☐ 3 |
Walk on even ground |
☐ 0 |
☐ 1 |
☐ 2 |
☐ 3 |
Sit down and get up |
☐ 0 |
☐ 1 |
☐ 2 |
☐ 3 |
Go up and down stairs |
☐ 0 |
☐ 1 |
☐ 2 |
☐ 3 |
Open the car door |
☐ 0 |
☐ 1 |
☐ 2 |
☐ 3 |
Grab an object above your head |
☐ 0 |
☐ 1 |
☐ 2 |
☐ 3 |
Lift a heavy object |
☐ 0 |
☐ 1 |
☐ 2 |
☐ 3 |
|
|
Treatment |
Regular medication |
Name of medication: |
_________________________________________________________ |
|
Name of medication: |
_________________________________________________________ |
|
Name of medication: |
_________________________________________________________ |
|
Name of medication: |
_________________________________________________________ |
|
|
|
Occasional medication |
Name of medication: |
_________________________________________________________ |
|
Efficacy of the medication: |
Absolutely no relief
from symptoms |
0 1 2 3 4 5 6 7
8 9 10 |
Complete relief
from symptoms |
|
|
|
Name of medication: |
_________________________________________________________ |
|
Efficacy of the medication: |
Absolutely no relief
from symptoms |
0 1 2 3 4 5 6 7
8 9 10 |
Complete relief
from symptoms |
|
|
|
|
Side effects |
☐ No side effects |
☐ Side effects (what were they?): ______________________________________________ |
_____________________________________________________________________________ |
|
|
|
Goals |
Improving symptoms |
I would like to see an improvement of the following symptoms: |
☐ Pain |
☐ Fatigue |
☐ Morning stiffness |
☐ Other : ___________________ |
|
|
Improving activities |
I would like to perform the following activities with more ease: |
☐ Getting in and out of the car |
☐ Doing my chores |
|
☐ Getting in and out of bed |
☐ Dressing myself |
|
☐ Exercising |
☐ Going up and down stairs |
|
☐ Doing groceries |
☐ Taking walks |
|
☐ Other: ______________________ |
|
|
|
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