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