Health Information

Rheumatologic Diseases:Screening Questionnaire

1) Do you feel persistent pain in one or more of your joints?
No Yes
if yes how many?
1 2-5 5
One side Both side

a) Do you have swelling in the above mentioned painful joints?
No Yes

b)Since how long have you been experiencing these problems?
Few months 1 yr 2-5 yrs >5 yrs

c) Whether the pain is due to a recent injury occurred while playing, at work or at home ?
No Yes
 
2) Do you have persistent low back pain or buttock pain for > 3 months, which is obstracting you sleep?
Low back pain Buttock Pain Both No
Pain after waking up
After excess of straining > 30 min
After prolonged sitting
Dose it impair your daily activities
a) Do you have early morning stiffness which improves or worsen with activity?
No Yes
stiffness > 30 min
stiffness < 30 min
improves with activity
worsen with activity

3) Do you have deformity in your hands, feet or back?
Yes No
Deformity in hands
Deformity in legs
Deformity in back
a) Are you experiencing any sound (crepitus) on moving the joint?
Yes No
b) Do you experiance excessive fatigue or feel abnormally feverish
Yes No

4 a) Do you have any of the following symptoms?
Generalized body pain
Difficulty in using upper or lower limb due to muscle weakness
Red skin rash with raised borders over your face, scalp, neck or behind ears
Flat facial skin rash over bridge of your nose, across cheeks which is non-itchy and scarring
Sleep disturbance
None
b) Do you have any problems below
Unusually / excessively sensitive to sunlight
Ulcers of mouth, nose or throat
Having excessive hair loss in last three months
Does your fingers and toes react to cold, turning blue
None
c)Have you experienced?
Irrational or disturbed thought process
Seizures
Personality changes
Anxiety
None
d) Do you have inflammation of kidney or abnormal urine analysis showing protein/cellular caste in the urine?
Yes No
e) Whether the clinical/ findings show any of the following?
Abnormal blood counts (leucopenia, thrombocytopenia, anemia)
Blood test positive for ds DNA, ANA, anti-Sm, anticardiolipin antibody, lupus anticoagulant, RO52, SSA or SSB
None
5) Do you have swelling in the glands around your face or neck?
Yes No
a) Do you have dental problems (i.e. dental decay, oral disease)
Yes No
b) Have you experienced any of the following in the last three months?
Gritting sensation in the eye
Redness of the eye
Use eye drops for dry eyes
None

6) Do you have one or frequent episodes of sudden onset of severe pain in big toe?
Yes No
a) Whether the uric acid value is
>8 <8

 
    Disclaimer:
  • This questionnaire is intended for informational purposes only and does not substitute medical advice or consultation.
  • Always consult your physician or other qualified health provider with any questions you may have regarding a medical condition.