Multi-Dimensional Health Assessment Questionnaire (R808-NP2)
This questionnaire includes information not available from blood tests, X-rays, or any source other
than you. Please try to answer each question, even if you do not think it is related to you at this
time. Try to complete as much as you can yourself, but if you need help, please ask. There are no
right or wrong answers. Please answer exactly as you think or feel. Thank you.
1. Please check
(
√)
the ONE best answer fo
r 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:
{
0
NO
PAIN
{
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
PAIN AS BAD AS
IT COULD BE
3. Please place a check
(
√)
in t
he appropriate spot to indicate the amount of pain you
are having today in each of the joint areas listed below:
None Mild Moderate Severe
a. LEFT FINGERS 0 1 2 3
b. LEFT WRIST 0 1 2 3
c. LEFT ELBOW 0 1 2 3
d. LEFT SHOULDER 0 1 2 3
e. LEFT HIP 0 1 2 3
f. LEFT KNEE 0 1 2 3
g. LEFT ANKLE 0 1 2 3
h. LEFT TOES 0 1 2 3
q. NECK 0 1 2 3
None Mild Moderate Severe
i. RIGHT FINGERS 0 1 2 3
j. RIGHT WRIST 0 1 2 3
k. RIGHT ELBOW 0 1 2 3
l. RIGH
T SHOULDER
0 1 2 3
m. RIGHT HIP 0 1 2 3
n. RIGHT KNEE 0 1 2 3
o. RIGHT ANKLE 0 1 2 3
p. RIGHT TOES 0 1 2 3
r. B
ACK 0 1 2 3
4. Considering all the ways in which illness and health conditions may affect you at this
time, please indicate below how you are doing:
{
0
VERY
WELL
{
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
VERY
POORLY
Please turn to the other side
Copyright: Health Report Services, Telephone 615-479-5303, E-mail tedpincus@gmail.com
FOR OFFICE
USE ONLY
1.a-j FN (0-10):
1=0.3
2=0.7
3=1.0
4=1.3
5=1.7
6=2.0
7=2.3
8=2.7
9=3.0
10=3.3
11=3.7
12=4.0
13=4.3
14=4.7
15=5.0
16=5.3
17=5.7
18=6.0
19=6.3
20=6.7
21=7.0
22=7.3
23=7.7
24=8.0
25=8.3
26=8.7
27=9.0
28=9.3
29=9.
7
30=10
2.PN (0-10):
4.PTGL (0-10):
RAPID 3 (0-30)
Cat:
HS = >12
MS = 6.1-12
LS = 3.1-6
R = <3
_____
______________________________________________________________
______________________________________________________________
5. Please check (√) if you have experienced any of the following o
ver the last month:
Fever
Weight gain (>10 lbs)
Weight loss (>10 lbs)
Feeling sickly
Headaches
Unusual fatigue
Swollen glands
Loss of appetite
Skin rash or hives
Unusual bruising or bleeding
Other skin problems
Loss of hair
Dry eyes
Other eye problems
Problems with hearing
Ringing in the ears
Stuffy nose
Sores in the mouth
Dry mouth
Problems with smell or taste
Lump in your throat
Cough
Shortness of breath
Wheezing
Pain in the chest
Heart pounding (palpitations)
Trouble swallowing
Heartburn or stomach gas
Stomach pain or cramps
Nausea
Vomiting
Constipation
Diarrhea
Dark or bloody stools
Problems with urination
Gynecological (female) problems
Dizziness
Losing your balance
Muscle pain, aches, or cramps
Muscle weakness
Paralysis of arms or legs
Numbness or tingling of arms or le
gs
Fainting spells
Swelling of hands
Swelling of ankles
Swelling in other join
ts
Joint pain
Back pain
Neck pain
Use of drugs not sold in stores
Smoking cigarettes
More than 2 alcoh
olic drinks per day
Depression - feeling blue
Anxiety - feeling nervous
Problems with thinking
Problems with memory
Problems with sleeping
Sexual problems
Burning in sex organs
Problems with social activities
Please check (√) here if you have had none of the above over the last month: ______.
FOR OFFICE
USE ONLY
5. ROS:
6. When you awakened in the morning OVER THE LAST WEEK, did you feel stiff?
No Yes
If “No,” please go to Item 7. If “Yes,” please indicate the number of minutes_______, or hours
until you are as limber as you will be for the day.
7. How do you feel TODAY compared to ONE WEEK AGO? Please check
(9) only one.
Much Better
� (1), Better � (2), the Same � (3), Worse � (4), Much Worse � (5) than one week ago
8. How oft
en do you exercise aerobically (sweating, increased heart rate, shortness of breath) for at least
one-half ho
ur (30 minutes)? Please check
(9) only o
ne.
3 or mor
e times a week (3)
1-2 times per month (1)
1-2 times per week (2)
Do not exercise regularly (0) Cannot exercise due to disability/ handicap (9)
9. How much of a problem has UNUSUAL fatigue or tiredness been for you OVER THE PAST WEEK?
FATIGUE IS
NO PROBLEM
{ { { { { { { { { { { { { { { { { { { { {
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
FATIGUE IS A
MAJOR PROBLEM
10. Over the last 6 months have you had: [Please check
(√)]
No Yes An operati
on or new illness
No Yes Medical emergency or stay overnight in hospital
No Yes A fall, broken bone, or other accident or trauma
No Yes An important new symptom or medical problem
No Yes Side effect(
s) of any medication or drug
No Yes Smoke cigarettes regularly
No Yes Change(s) of arthritis or other medication
No Yes Change(s) of address
No Yes Change(s) of marital status
No Y
es Change job or work duties, quit work, retired
No Yes Change of medical insurance, Medicare, etc.
No Yes Change of primary care or other doctor
Please explain any "Yes" answer below, or indicate any other health matter that affects you:
SEX:
Female, Male ETHNIC GROUP:
Asian, Black, Hispanic, White, Other_________________
Your Occupation __________________________
Work Status: Full-time, Part-time, Disabled
Homemaker, Self-Employed,
Retired,
Seeking work, Other_________________
Please
cir
cle
the
numbe
r
of
ye
ar
s
of
school
you
ha
ve
completed:
1 2 3 4 5 6 7 8 9 10
11 12 13 14 15 16 17 18 19 20
Please write your weight: _____ lbs. height: _____ inches
Your Name
_____________________________________ Date of Birth ____________ ______________
Today’s Date
Page 2 of 2 Thank you for completing this questionnaire to help keep track of your medical care. R808NP2
FOR OFFICE USE ONLY: I have reviewed the questionnaire responses.
Date: ______________________________ Signature______________________________________________
Date: ______________________________ Signature___
___________________________________________
