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.
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 | Activities | |||||
|---|---|---|---|---|---|---|
| Check the boxes that correspond to where you have joint pain. | 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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The patient information leaflets are provided by Vigilance Santé Inc. This content is for information purposes only and does not in any manner whatsoever replace the opinion or advice of your health care professional. Always consult a health care professional before making a decision about your medication or treatment.