Arthritis Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Name *FirstLastEmail *Phone *SexMaleFemaleDate of BirthMarital statusEthnicityCaucasian Hispanic Native American African-American Other 1. How much pain have you had in the past week because of your arthritis? 0-495051-100Please select the option to indicate the severity of your pain.Considering all the ways your arthritis affects you, mark “X” on the scale for how well you are doing?0-495051-100Please select the option to indicate the severity of your pain.What is kind of work you do comfortably? Check all that apply. Sitting only Sitting and walking Physical work more than hourStading hours in a row Cooking Housecleaning Exercise moderatley No exercise at all Are your disabiled or retired, if yes since when? How many days of work l have you missed because of your arthritis this year?Have you had to reduce your working hours because of your arthritis? NoYesIf so, what kind, How many hours/week, and at what Have you had to change your duties at work because of your arthritis? NoYesIf so, How? Have you had to hire help for work at home because of your arthritis? NoYesIf so, what kind, How many hours/week, and at what Are you able toDress yourself, including tying shoe laces : Without ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Close and open buttonsWithout ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Shampoo your hair: Without ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Stand up from an armless straight chair: Without ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Get in and out of bedWithout ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL EATING are you able toWithout ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Lift a full cup or glass to your mouthWithout ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Open a new milk cartonWithout ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Walk outdoors on flat groundWithout ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Climb up five (5) steps: Without ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL ABLE to do HYGIENE Without ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL ARE you able to Wash and dry your entire bodyWithout ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL TAKE a tub bathWithout ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Get on and off the toiletWithout ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Are you able to reach and get down a 5 lb object (such as a bag of sugar) from just above your headWithout ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Bend down to pick up clothing from the floorWithout ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Are you able to open car doorsWithout ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Open jars which have been previously openedWithout ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Turn faucets on and off: Without ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Run errands and shop: Without ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Get in and out of a car: Without ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Do chores such as vacuuming or yard workWithout ANY Difficulty With SOME Difficulty With MUCH Difficulty Not AT ALL Please check any AIDS or DEVICES that you usually use for any of these activitiesCane Wheelchair Walker Special or built up chair Devices used for Dressing (button, hook, zipper pull, long-handled shoe horn, etc.) Back support (home) Back support (car) Other specifyPlease check any categories for which you usually need HELP FROM ANOTHER PERSON: Dressing & Grooming Eating Arising Walking None Please check any AIDS or DEVICES that you usually use for any of these activities. Raised Toilet Seat Bathroom Bar Bathtub Seat ong-Handled Appliances for Reach_________ Jar Opener (for jars previously opened)Long-Handled Appliances in Bathroom Other specifyPlease check any categories for which you usually need HELP FROM ANTOHER PERSONHygieneGripping and opening things Reach Errands and ChoresWe are interested in knowing how your illness affects the daily activities of your life. Please feel free to add comments on bottom. WebsiteSubmit