1. Pain | ||||||||||||
Circle the number that best describes the pain you felt due to your rheumatoid arthritis during the last week: | ||||||||||||
None | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | Extreme |
2. Functional disability assessment | ||||||||||||
Circle the number that best describes the difficulty you had in doing daily physical activities due to your rheumatoid arthritis during the last week: | ||||||||||||
No difficulty | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | Extreme difficulty |
3. Fatigue | ||||||||||||
Circle the number that best describes how much fatigue you felt due to your rheumatoid arthritis during the last week: | ||||||||||||
No fatigue | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | Totally exhausted |
4. Sleep | ||||||||||||
Circle the number that best describes the difficulty the sleep difficulties (i.e., resting at night) you felt due to your rheumatoid arthritis during the last week: | ||||||||||||
No difficulty | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | Extreme difficulty |
5. Physical well-being | ||||||||||||
Considering your arthritis overall, how would you rate your level of physical wellbeing during the past week? Circle the number that best describe your level of physical well-being: | ||||||||||||
Very good | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | Very bad |
6. Emotional well-being | ||||||||||||
Considering your arthritis overall, how would you rate your level of emotional well being during the past week? Circle the number that best describes your level of emotional well-being: | ||||||||||||
Very good | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | Very bad |
7. Coping | ||||||||||||
Considering your arthritis overall, how well did you cope (manage, deal, make do) with your disease during the last week: | ||||||||||||
Very well | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | Very poorly |