Rheumatoid arthritis review

About you

Height (in Meters): *

eg. 1.75

Weight (in Kilograms): *

eg. 60.6

BMI:

Alcohol consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? *

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Smoking

Smoking status: *

Smoker

Never smoked

Ex smoker

Smoker

What do you mainly smoke?

How many cigarettes do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco do you smoke per week? *

Pipe – How many grams of tobacco do you smoke per week? *

Would you like to give up smoking? *

Yes

No

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

Ex smoker

What did you mainly smoke?

How many cigarettes did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco did you smoke per week? *

Pipe – How many grams of tobacco did you smoke per week? *

When did you quit smoking? *

Blood pressure

Please provide a blood pressure reading if you have access to a machine.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Review

We are interested in learning how your illness affects your ability to function in daily life. In the last week, how would you rate your ability to do each of the following tasks?

Stand up from a straight chair: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Walk outdoors on flat ground: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Get on/off toilet: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Reach and get down an object (such as a bag of sugar) from just above your head: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Open car doors: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Do outside work (such as gardening): *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Wait in a line for 15 minutes: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Lift heavy objects: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Move heavy objects: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Go up two or more flights of stairs: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

When you get up in the morning do you feel stiff?

Yes

No

Length of time until you are as limber as you will be for the day:

Further questions

Are you happy with your treatment?

Have you had recent changes in your treatment or flares of your disease?

Do you feel you need more support or aids at home and if so, can you describe why and what you think you might need?

Have you had any falls in the last year? If so, how many?

Do you feel that you are managing and tolerating your current medications?

Do you have any questions about your medications?

Is there any history of osteoporosis in your family?

Over the last 2 weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things:

Not at all

On Several days

More than half the days

Nearly every day

Feeling down, depressed or hopeless:

Not at all

On Several days

More than half the days

Nearly every day

Before you submit your review

Any further information about your arthritis:

Terms and conditions

I confirm that this is not an emergency and understand the surgery cannot help while it is closed. If I need help right now, I will use the NHS 111 service. In an emergency, I will call 999 or go to A&E.