Step 1 of 2 50% Personal DetailsFirst name * REQUIRED Middle name Surname * REQUIRED Date of Birth * REQUIREDDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ethnicity * REQUIREDWhite: British (England, Wales or Northern Ireland)White: IrishWhite: EuropeanWhite: OtherBlack or Black British: AfricanBlack or Black British: CaribbeanBlack or Black British: OtherAsian or British Asian: IndianAsian or British Asian: PakistaniAsian or British Asian: BangladeshiAsian or British Asian: ChineseAsian or British Asian: OtherMixed: White and BlackMixed: White and AsianMixed: Black and AsianMixed: OtherDo not wish to disclose ethnicityGP Name Name of person completing form * REQUIRED Address line 1 * REQUIRED Address line 2 * REQUIRED Address line 3 Town Postcode * REQUIRED GP Surgery Relationship to Child * REQUIREDMotherFatherGuardianCarerOtherRelationship to Child (other) Contact detailsMobile Phone No Home Phone No Work Phone No Email address * REQUIRED Preferred Contact Method * REQUIRED Mobile Home Work Email We are interested in hearing how your child's illness affects his/her ability to function in daily life. In the following questions, please tick the one response which best describes his/her usual activities OVER THE PAST WEEK. ONLY NOTE THOSE DIFFICULTIES OR LIMITATIONS WHICH ARE DUE TO ILLNESS. If most children at your child's age are not expected to do a certain activity, please mark it as 'not applicable'. For example if your child has difficulty in doing a certain activity or is unable to do it because he/she is too young, but not because he/she is RESTRICTED BY ILLNESS, please mark it as 'not applicable' In the end, please go back and check once again that every item has been answered.Dressing & Personal CareIs your child able to dress, including tying shoelaces and doing buttons? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to shampoo his/her hair? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to remove his/her socks? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to cut his/her fingernails? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Getting UpIs your child able to stand up from a low chair or floor? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to get in and out of bed? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable EatingIs your child able to cut his/her own meat? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to lift a cup or glass to his/her mouth? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to open a new cereal box? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable WalkingIs your child able to walk outside on flat ground? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to climb up five steps? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable HygieneIs your child able to wash and dry their entire body? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to take a bath (get in and get out)? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to get on and off the toilet? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to brush his/her teeth? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to comb or brush his/her hair? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable ReachIs your child able to reach and get down a heavy object such as a large game or books from just above his/her head? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to bend down to pick up clothing or a piece of paper from the floor? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to pull on a jumper over his/her head? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to turn his/her neck to look back over his/her shoulder? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable GripIs your child able to write with pen or pencil? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to open car doors? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to open jars which have been previously opened? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to turn taps on and off? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to push open a door when they have to turn a door knob? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable ActivitiesIs your child able to run errands and shop? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to get in an out of a car or school bus? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to ride a bike or a tricycle? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to do household chores eg wash dishes, take out rubbish, hoovering, gardening, make bed, clean room? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Is your child able to run? * REQUIRED Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Not applicable Aids or DevicesPlease tick any AIDS or DEVICES that your child usually uses for any of the above activities: Walking stick Walking frame Crutches Wheelchair Built up pencil or special utensils Special or built up chair Raised toilet seat Bath seat Jar opener (for jars previously opened) Bath rail Long-handled appliances for reach Long-handled appliances in bathroom Other (if other please provide details in box below) Please detail any AIDS or DEVICES not covered in the check boxes aboveHelp RequiredPlease tick any categories for which your child usually needs help from another person BECAUSE OF PAIN OR ILLNESS: Getting up Eating Walking Hygiene Reach Gripping and opening things Errands and chores PainHow much pain do you think your child has had IN THE PAST WEEK? This is on a scale of 0 to 100 where 0 = No Pain and 100 = Very severe pain General EvaluationConsidering all the ways that arthritis affects your child, rate how he/she is doing. This is on a scale of 0 to 100 where 0 = Very well and 100 = Very poor CAPTCHA