Patient Questionnaire


This information will help your doctors keep track of how you feel and how well you are able to do your usual activities. Answer every question by placing a check mark on the line in front of the appropriate answer. It is not specific for arthritis. If you are unsure about how to answer a question, please give the best answer you can and make a written comment beside your answer.


  • ExcellentVery GoodGoodFairPoor


The following two questions are about activities you might do during a typical day. Does YOUR HEALTH NOW LIMIT YOU in these activities? If so, how much?


  • Yes, Limited A LotYes, Limited A LittleNo, Not Limited At All
  • Yes, Limited A LotYes, Limited A LittleNo, Not Limited At All


During the PAST 4 WEEKS have you had any of the following problems with your work or other regular activities AS A RESULT OF YOUR PHYSICAL HEALTH?


  • YesNo
  • YesNo


During the PAST 4 WEEKS, were you limited in the kind of work you do or other regular activities AS A RESULT OF ANY EMOTIONAL PROBLEMS (such as feeling depressed or anxious)?


  • YesNo
  • yesNo
  • Not At AllA Little BitModeratelyQuite A BitExtremely


The next three questions are about how you feel and how things have been DURING THE PAST 4 WEEKS. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the PAST 4 WEEKS –


  • All of the TimeMost of the TimeA Good Bit of the TimeSome of the TimeA Little of the TimeNone of the Time
  • All of the TimeMost of the TimeA Good Bit of the TimeSome of the TimeA Little of the TimeNone of the Time
  • All of the TimeMost of the TimeA Good Bit of the TimeSome of the TimeA Little of the TimeNone of the Time