Unite with Fellow Rheumatoid Arthritis Patients by Filling out this Health Assessment Questionnaire:

Shows you how well your medicines, foods, complementary strategies and alternative treatments tame your rheumatoid arthritis.

Just by filling out a Health Assessment Questionnaire on your rheumatoid arthritis at least every week.

Drinking more water eased the rheumatoid arthritis pain in me everyday from day 1.

However, many alternative and complementary treatments may take one week to several months or more to have an effect on rheumatoid arthritis.

If you’d like to share information on how well various foods, complementary strategies and alternative treatments have tamed your rheumatoid arthritis, feel free to send me a testimonial.

Here’s suggestions for filling out your health assessment questionnaire (HAQ).

If the question requests a number between 0 – 9, where 0 is no occurrence and 9 is always, please mark a number or you can give a range on the line.

Please write all comments on your general health or rheumatoid arthritis or weather on the last page.

Note: This survey is based on the Health Assessment Questionnaire (HAQ) developed by Stanford University for assessing the ability of pharmaceutical preparations to relieve rheumatoid arthritis symptoms.

Health Assessment Questionnaire (HAQ) for Rheumatoid-Arthritis-Decisions.com

Please fill in the blanks:

Initials____________________________ Date: ___ / ____/ 20___

How long have you been diagnosed with rheumatoid arthritis? _______yrs

For questions with a short _____, please mark the correct item(s) with an x.

My rheumatoid arthritis began with:

____a fever, ____an accident.____other__ describe____________.

My rheumatoid arthritis affects:

______my fingers, ____my hands / wrists, ______my elbows, ______my shoulders, _____my neck, _____my back, ______my toes, _____my feet / ankles, ______my knees, ______my hips.

My blood tests reveal:

Rf factor ___ Negative ___Positive Titer, _______ ____Not tested

Anti-CCP ___ Negative ___Positive Titer _______ ____Not tested

HLA-DR4 ___ Negative ___Positive ____Not tested

Who diagnosed your rheumatoid arthritis? ___Primary Physician ___Rheumatologist ___ self

How did your arthritis affect your ability to carry out your daily life this week?

Please mark 0 if you can always do it and have no difficulty with the task, mark 2 if you can usually do it, although you have some difficulty, mark 4 if you can sometimes do it but you usually have much difficulty, and mark 6 if you are unable do it.

Dressing and Grooming: Are you able to:

Dress yourself including shoelaces and buttons _____

Shampoo your hair ______

Arising: Are you able to:

Stand up from a straight chair _________

Get in and out of bed _________

Eating: Are you able to:

Cut your meat __________

Lift a full glass to your mouth __________

Open a new milk carton __________

Walking: Are you able to:

Walk outdoors on flat ground __________

Climb 5 steps __________

Go down five steps __________

Walk on uneven ground __________

Please check any aids or Devices that you usually use for any of the above activities: ________Aids used for dressing (button hook, zipper pull)

________Special or built up chair ________Built up or special utensils ________Cane, ________Walker, ________Crutches ________wheelchair

Please check any categories that you usually need help from another person:

________Dressing and Grooming, ________Arising,________Eating,________Walking

How did your arthritis affects your ability to carry out these tasks this week?

Please mark 0 if you can always do it and have no difficulty with the task, mark 2 if you can usually do it, although you have some difficulty, mark 4 if you can sometimes do it but you usually have much difficulty, and mark 6 if you are unable do it.

Hygiene: Are you able to:

Wash and dry your body? __________

Take a tub bath? __________

Get on and off the toilet? __________

Reach: Are you able to:

Reach above your head and get down a 5 lb bag of sugar? __________

Bend down to pick up clothing from the floor __________

Grip: Are you able to:

Open car doors? __________

Open previously opened jars? __________

Turn faucets on and off? __________

Activities: Are you able to:

Run errands and shop? __________

Get in and out of a car? __________

Do chores such as vacuuming and yard work? __________

Dance __________ Golf __________

Swim __________

Please check any Aids or Devices that you usually use for any of the above activities: ________Raised toilet seat

________Bathtub seat, ________Bathtub bar ________Long handled appliances in bathroom ________Long handled appliances for reach

________Jar opener (for previously opened jars)

Please check any categories that you usually need help from another person: ________Hygiene, ________Reach, ________Grip, ________Activities

How’s your Overall Health?

In general, would you say that your overall health is: ____excellent, _____very good, ____good, ____fair, or _____poor.

Morning stiffness Are you stiff in the morning? ___yes ___no

If yes, how long does the stiffness last: ___hours, ____minutes

Pain Please mark how much pain you have had in the last week: Place a single vertical line (/) through the line to indicate the severity of pain.

None Severe 0____________________________________________________________100

When you wake up in the morning, do you ache? ___yes ___no.

If yes, how long does your pain last? ____ Do you take anything for pain? ____yes, ____no. If yes, please list:______________________________________

and its dosage________

Symptoms

Have you had any of these symptoms today, this past week, this past month? Please put an x on each line that is true.

General

Fever _____today, _____this week, _____this month

Dizziness _____today, _____this week, _____this month

Tiredness (fatigue)_____today, _____this week, _____this month

Head, eyes, ears, nose, mouth, throat

Blurred vision ______today, _____this week, _____this month.

Ringing in your ears:_____today, _____this week, _____this month

Hearing difficulties _____today, _____week, _____this month

Mouth sores _____today, _____this week, _____this month

Dry mouth _____today, _____this week, _____this month Loss, change in taste_____today, _____this week, _____this month

Headache _____today, _____this week, _____this month

Chest, lungs and heart

Chest pain ______today, _____this week, _____this month.

Shortness of breath: ______today, _____week, _____this month.

Wheezing: ______today, _____this week, _____this month.

Musculoskeletal:

Joint pain: ______today, _____this week, _____this month.

Joint swelling: ______today, _____this week, _____this month.

Leg or ankle swelling ______today, _____week, _____ month.

Low back pain ______today, _____this week, _____this month.

Muscle pain ______today, _____this week, _____this month.

Neck pain ______today, _____this week, _____this month.

Weakness of muscles ______today, _____week, _____ month.

Gastrointestinal tract:

Loss of appetite______today, _____this week, _____this month.

Nausea ______today, _____this week, _____this month.

Heartburn ______today, _____this week, _____this month.

Indigestion ______today, _____this week, _____this month.

Pain in stomach area ___today, ___this week, _____this month.

Liver problems ______today, _____this week, _____this month.

Pain in lower abdomen____today, ____this week, _____this month.

Diarrhea-severe and frequent ______today, _____week, _____month.

Constipation ______today, _____this week, _____this month.

Black or tarry stools______today, _____this week, _____month.

Vomitting ______today, _____this week, _____this month.

Neurological and Psychological

Sadness ______today, _____this week, _____this month

Depression ______today, _____this week, _____this month.

Insomnia ______today, _____this week, _____this month.

Nervousness ______today, _____this week, _____this month.

Trouble thinking______today, _____this week, _____this month.

Skin

Easy bruising ______today, _____this week, _____this month.

Hives or welts ______today, _____this week, _____this month.

Itching ______today, _____this week, _____this month.

Rash ______today, _____this week, _____this month.

Pregnancy ______

What changes are you making to your daily routine?

Water

I drank ______ glasses of water before. I now drink _______ glasses of water daily

The water I drink is ___tap ___bottled (brand________ or ____mixed brands), _____filtered, ______distilled.

Exercise:

I exercise _____daily, _____weekly, ______monthly.

I ____walk, ____do yoga, _____ water exercises, _____garden, ____dance, Other_________________________________________________________

Eating Habits

Breakfast:

I usually eat a ____hearty / _______light breakfast.

I usually ___ do ____do not snack before lunch.

Lunch:

I usually eat a ____hearty/ _______light lunch.

I usually ___ do ____do not snack before dinner.

Dinner:

I usually eat a ____light/ _______hearty dinner.

I usually ___ do ____do not snack before going to bed.

Each week I usually eat ______ servings of vegetables that are ___ conventional _____organic

______ servings of fruit a day that are ___ conventional _____organic

______ protein (eggs, meat, tofu, beans) that are ___ conventional _____organic, or ______pastured.

_______raw brazil nuts (1-2), _____raw almonds, _______roasted nuts

______ fat ______olive oil, ______organic or ____ conventional butter,

______ vegetable oils ________hydrogenated oils _______fish oil ______fried foods

______sea salt, _____table salt

Changing:

I am changing ___________________________________.

I have been ________________________________daily for ___today, ____weeks, or ______months.

May all your stiffness lift and your pain dissolve!

Disclaimer: Please note that the information on this website is a sharing of information and knowledge from the research and experience of Dr. Molnar-Kimber and her community. It is not intended to replace your one on one relationship with a qualified health care professional. It also is not intended to be medical advice. However, it is often observed that patients who take a major interest in their disease and learn as much as they can about their disease and potential treatments often improve faster than those who don’t. Dr. Molnar-Kimber encourages you to make your own health care decisions based upon your own research and discussions with your qualified health care professional. 2006-2007 © Katherine L. Molnar-Kimber, Ph.D.