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Date________
Patient Number_______ Patient Initials ___
PLEASE
COMPLETE EACH QUESTION!!!
Section 1:
Instructions: Complete each question by marking one number per
question. 4 is good 1 is bad.
4 is no
difficulty
3 is some
difficulty
2 is much
difficulty and
1 is unable
to do.
Example
question:
Are you able to answer questions?
4 X 3__
2__ 1__
You answer was 4 indicated by the mark X indicating
that you have no difficulty answering questions. You may also
circle the number you choose.
ARE YOU ABLE
TO:
DRESSING AND
GROOMING:
1. dress
yourself , including tying shoelaces and doing buttons?
4___ 3___ 2___ 1___
2. Shampoo
your hair? 4___
3___ 2___ 1____
ARISING:
3. stand up
straight from an armless straight chair?
4__ 3__
2 ___ 1___.
4. get in
and out of bed? 4___
3____ 2___ 1____
Section one
continued.
ARE YOU ABLE
TO:
EATING:
5. cut your
(meat) food? 4___3____
2____1____
6. lift a
full cup or glass to your mouth? 4__
3___2___1__
7. open a
new milk carton? 4___ 3____ 2____1____.
WALKING:
8. walk out
doors on flat ground? 4__
3___2___ 1___.
9. climb up
five stairs? 4___ 3___ 2___ 1____.
HYGEINE:
10. wash and
dry your entire body? 4___
3___ 2___ 1___.
11. take a
tub bath? 4___
3____ 2___ 1____.
12. get on
and off the toilet? 4___ 3___ 2___ 1___.
REACHING:
13. reach
and get down a five-pound object from a shelf above eye level.
14. bend
down and pick up clothing from the floor.?
4__ 3__ 2__ 1___.
GRIPPING:
15. open car
door? 4__ 3___ 2___ 1___.
16. open
jars which have been previously open?
17. turn regular faucets off?
4___ 3___ 2___ 1___.
Section one
continued:
ARE YOU ABLE
TO:
OTHER
ACTIVITIES:
18. run
errands and shop? 4___ 3___ 2___ 1____
19. get in
and out of a car? 4___ 3___2___1____
20. do
chores such as vacuuming or yard work?
4___ 3___2___ 1____.
SECTION TWO:
PLEASE RATE
THE SEVERITY OF THE FOLLOWING PROBLEMS YOU EXPERIENCED IN THE
LAST WEEK. IF YOU DID NOT HAVE ANY PROBLEM DURING THE LAST WEEK
THEN MARK 10 AND IF YOU HAD VERY SEVERE PROBLEMS MARK ONE.
PLEASE MARK
EACH QUESTION?
Sample
question. In the
past week how much difficulty have you had in answering
questions? 10 is very good and 1 is very bad.
10_X_
9___8___ 7___ 6___ 5___ 4___ 3___ 2___ 1___
Your answer
was 10_X_. You may also circle the number.
_
21. In the
past week, how much have your INTESTINAL problems interfered
with your daily activities?
10___ 9___
8___ 7___ 6___ 5___ 4___ 3___ 2___ 1____
22. In the
past week how much have your BREATHING problems interfered with
your daily activities?
10___ 9___ 8___ 7___ 6___ 5___ 4___ 3___ 2___ 1____
SECTION TWO
CONTINUED:
23. In the
last week, how much have your RAYNAOUD’S attacks interfered
with your daily activities?
10___ 9___
8___ 7___ 6___ 5___ 4___ 3___ 2___ 1___
24. In the
last week, how much have your FINGER ULCERS interfered with your
daily activities?
10 ___ 9___
8___ 7___ 6___ 5___ 4___ 3___ 2___ 1____
25. OVERALL,
considering your PAIN, DISCOMFORT, and LIMATATIONS during the
last week: where would your rate your total disease SEVERITY?
10___ 9___
8___ 7___ 6___ 5___ 4___ 3___ 2___ 1____
SECTION
THREE:
SKIN
EVALUATION:
Instructions:
On a five point scale how would you rate your skin symptoms.
5 being a lot better
4 a little
better
3 is no
better
2 is a
little worse
1 is a lot
worse:
Mark your
answer number with an X or a circle and answer each question.
26. In the
last week, how much PAIN from your skin have you experienced?
5___ 4____ 3____ 2____ 1___.
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