Rheumatoid arthritis review

Which surgery are you registered at?

About you

eg. 1.75
eg. 60.6

Alcohol consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Smoking

Smoking status: *

Smoker

What do you mainly smoke?
How many cigarettes do you smoke in a day? *
How many cigars do you smoke in a day? *
Would you like to give up smoking? *

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

Ex smoker

What did you mainly smoke?
How many cigarettes did you smoke in a day? *
How many cigars did you smoke in a day? *

Blood pressure

Please provide a blood pressure reading if you have access to a machine.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Please use date format: DD/MM/YYYY

Review

We are interested in learning how your illness affects your ability to function in daily life. In the last week, how would you rate your ability to do each of the following tasks?

Stand up from a straight chair: *
Walk outdoors on flat ground: *
Get on/off toilet: *
Reach and get down an object (such as a bag of sugar) from just above your head: *
Open car doors: *
Do outside work (such as gardening): *
Wait in a line for 15 minutes: *
Lift heavy objects: *
Move heavy objects: *
Go up two or more flights of stairs: *

How much pain have you felt over the past week?
On a scale of 0 being “no pain” and 10 being “severe pain”
How much of a problem has unusual fatigue or tiredness been for you over the past week?
On a scale of 0 being “no fatigue” and 10 being “severe fatigue”
How much of a problem has sleeping been for you over the past week?
On a scale of 0 being “no difficulty sleeping” and 10 being “severe difficulty sleeping”
How active has your arthritis been in the last 24 hours?
On a scale of 0 being “not active” and 10 being “very active”
When you get up in the morning do you feel stiff?

Further questions

Over the last 2 weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things:
Feeling down, depressed or hopeless:

Before you submit your review

Terms and conditions