/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/questionnaires/,

/clinical/cckm-tools/content/questionnaires/name-97151-en.cckm

20170494

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Questionnaires

RAPID 3 - Health Assessment Questionnaire (301931-DT)

RAPID 3 - Health Assessment Questionnaire (301931-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #

Index to Questionnaire-Health\Encounter

UWH301931-DT (Rev. 03/31/17) RAPID-3/HEALTH ASSESSMENT QUESTIONNAIRE
Page 1 of 2
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
RAPID-3/HEALTH ASSESSMENT QUESTIONNAIRE


Date: _________________________________

This questionnaire includes information not available from blood tests, x-rays or any other source we have.
Complete as much as you can, but if you need help, please ask.

1. Please check () the ONE best answer for your abilities at this time:
OVER THE LAST WEEK, were you able to:
Without
ANY
Difficulty
With
SOME
Difficulty
With
MUCH
Difficulty
UNABLE
To Do
a. Dress yourself, including tying shoelaces and doing
buttons?
____0 ____1 ____2 ____3
b. Get in and out of bed? ____0 ____1 ____2 ____3
c. Lift a full cup or glass to your mouth? ____0 ____1 ____2 ____3
d. Walk outdoors on flat ground? ____0 ____1 ____2 ____3
e. Wash and dry your entire body? ____0 ____1 ____2 ____3
f. Bend down to pick up clothing from the floor? ____0 ____1 ____2 ____3
g. Turn regular faucets on and off? ____0 ____1 ____2 ____3
h. Get in and out of a car, bus, train, or airplane? ____0 ____1 ____2 ____3
i. Walk two miles or three kilometers, if you wish? ____0 ____1 ____2 ____3
j. Participate in recreational activities and sports as you
would like, if you wish? ____0 ____1 ____2

____3
k. Get a good night’s sleep? ____0 ____1.1 ____2.2 ____3.3
l. Deal with feelings of anxiety or being nervous? ____0 ____1.1 ____2.2 ____3.3
m. Deal with feelings of depression or feeling blue? ____0 ____1.1 ____2.2 ____3.3

2. How much pain have you had because of your condition OVER THE PAST WEEK?
Please indicate below how severe your pain has been:
NO PAIN PAIN AS BAD AS IT COULD BE
O O O O O O O O O O O O O O O O O O O O O
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0

3. Considering all the ways in which illness and health conditions may affect you at this time,
please indicate below how you are doing:
VERY WELL VERY POORLY
O O O O O O O O O O O O O O O O O O O O O
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0

PHYSICIAN USE ONLY
PHYSICIAN GLOBAL ASSESSMENT OF CURRENT RA ACTIVITY TODAY
NO ACTIVITY HIGH ACTIVITY
O O O O O O O O O O O O O O O O O O O O O
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0
Optional

Sh
o
ul
de
r
s

El
b
ow
s
Wr
is
t

MC
P1

T
hu
mb

MC
P2

MC
P3

MC
P4

MC
P5

PI
P
1
T
hu
mb

PI
P
2

PI
P
3

PI
P
4
PI
P
5

Kn
e
es

R L R L R L R L R L R L R L R L R L R L R L R L R L R L
Swelling
Pain/Tenderness
FOR OFFICE
USE ONLY


1=0.3 16=5.3
2=0.7 17=5.7
3=1.0 18=6.0
4=1.3 19=6.3
5=1.7 20=6.7
6=2.0 21=7.0
7=2.3 22=7.3
8=2.7 23=7.7
9=3.0 24=8.0
10=3.3 25=8.3
11=3.7 26=8.7
12=4.0 27=9.0
13=4.3 28=9.3
14=4.7 29=9.7
15=5.0 30=10

1. a-j Function
(0-10):





2. PN
(0-10):





3. Pt Global
(0-10):





Rapid 3 Total








MD Global

Swollen


Tender




Patient Name

DOB:

MR #

Index to Questionnaire-Health\Encounter

UWH301931-DT (Rev. 03/31/17) RAPID-3/HEALTH ASSESSMENT QUESTIONNAIRE
Page 2 of 2
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
RAPID-3/HEALTH ASSESSMENT QUESTIONNAIRE



4. Please check if you have experienced any of the following over the last month:
Weight gain (> 10 LBS) Cough Paralysis of arms or legs
Weight loss (< 10 LBS) Shortness of breath Numbness or tingling of arms or legs
Feeling ill Wheezing Fainting spells
Headaches Pain in the chest Swelling of hands
Unusual fatigue Heart pounding (palpitations) Swelling in other joints
Swollen glands Heartburn or acid reflux Joint pain
Loss of appetite Lump in your throat Back pain
Skin rash or hives Trouble swallowing Neck pain
Other skin problems Stomach pain or cramps Use of drugs not sold in stores
Unusual bruising or bleeding Nausea Smoking cigarettes
Loss of hair Vomiting More than 2 drinks/day
Dry eyes Constipation Depression – Feeling blue
Other eye problems Diarrhea Anxiety – Feeling nervous
Problems with hearing Dark or bloody stools Problems with thinking
Ringing in the ears Problems with urination Sleep problems
Stuffy nose Gynecological (female) problems Problems with memory
Sores in the mouth Dizziness Sexual problems
Dry mouth Losing your balance Social problems
Problems with smell or taste Muscle pain, aches or cramps Muscle weakness
Morning joint stiffness
















Copyright: Health Report Services, Telephone 615-479-5303, E-mail tedpincus@gmail.com

Signature of Patient/Representative _________________________________Date:__________Time:________AM/PM

If signed by person other than the patient, print name and state relationship and authority to do so.

Print Name: _____________________________________Relationship: __________________________________

Patient is:  Minor  Incompetent / Incapacitated
Legal Authority:  Legal Guardian  Parent of Minor  Health Care Agent  Other ___________________


Reviewed by: ___________________________________________________ Date: _____________Time: __________ AM/PM