Form Page | Gloucestershire Health and Care NHS Foundation Trust

We are interested in hearing how your illness affects your ability to function in daily life. In the following questions, please tick the one response which best describes your usual activities OVER THE PAST WEEK. ONLY NOTE THOSE DIFFICULTIES OR LIMITATIONS WHICH ARE DUE TO ILLNESS.
In the end, please go back and check once again that every item has been answered.

Dressing & Personal Care

Are you able to dress, including tying shoelaces and doing buttons? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to shampoo your hair? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to remove socks? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to cut fingernails? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Getting Up

Are you able to stand up from a low chair or floor? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to get in and out of bed? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Eating

Are you able to cut your own meat? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to lift a cup or glass to your mouth? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to open a new cereal box? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Walking

Are you able to walk outside on flat ground? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to climb up five steps? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Hygiene

Are you able to wash and dry your entire body? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to take a bath (get in and get out)? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to get on and off the toilet? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to brush your teeth? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to comb or brush your hair? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Reach

Are you able to reach and get down a heavy object such as a large game or books from just above your head? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to bend down to pick up clothing or a piece of paper from the floor? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to pull on a jumper over your head? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to turn your neck to look back over your shoulder? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Grip

Are you able to write with pen or pencil? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to open car doors? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to open jars which have been previously opened? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to turn taps on and off? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to push open a door when you have to turn a door knob? * *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Activities

Are you able to run errands and shop? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to get in an out of a car or school bus? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to ride a bike or a tricycle? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to do household chores eg wash dishes, take out rubbish, hoovering, gardening, make bed, clean room? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Are you able to run? *

Without ANY difficulty
With SOME difficulty
With MUCH difficulty
UNABLE to do
Not applicable

Aids or Devices

Please tick any AIDS or DEVICES that your child usually uses for any of the above activities:

Please detail any AIDS or DEVICES not covered in the check boxes above

Help Required

Please 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

Pain

How 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 Evaluation

Considering 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

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