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 Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *SexMaleFemaleMarital statusEthnicityCaucasianHispanicNative AmericanAfrican-AmericanOther1. 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 onlySitting and walkingPhysical work more than hourStading hours in a rowCookingHousecleaningExercise moderatleyNo exercise at allAre 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 DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLClose and open buttonsWithout ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLShampoo your hair: Without ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLStand up from an armless straight chair: Without ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLGet in and out of bedWithout ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLEATING are you able toWithout ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLLift a full cup or glass to your mouthWithout ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLOpen a new milk cartonWithout ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLWalk outdoors on flat groundWithout ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLClimb up five (5) steps: Without ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLABLE to do HYGIENE Without ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLARE you able to Wash and dry your entire bodyWithout ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLTAKE a tub bathWithout ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLGet on and off the toiletWithout ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLAre you able to reach and get down a 5 lb object (such as a bag of sugar) from just above your headWithout ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLBend down to pick up clothing from the floorWithout ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLAre you able to open car doorsWithout ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLOpen jars which have been previously openedWithout ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLTurn faucets on and off: Without ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLRun errands and shop: Without ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALL Get in and out of a car: Without ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLDo chores such as vacuuming or yard workWithout ANY DifficultyWith SOME DifficultyWith MUCH DifficultyNot AT ALLPlease check any AIDS or DEVICES that you usually use for any of these activitiesCaneWheelchairWalkerSpecial or built up chairDevices 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 & GroomingEatingArisingWalkingNonePlease check any AIDS or DEVICES that you usually use for any of these activities. Raised Toilet SeatBathroom BarBathtub Seatong-Handled Appliances for Reach_________ Jar Opener (for jars previously opened)Long-Handled Appliances in BathroomOther specifyPlease check any categories for which you usually need HELP FROM ANTOHER PERSONHygieneGripping and opening thingsReachErrands 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