irishhealth.com Rheumatoid Arthritis Clinic

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Required fields are indicated with a *

* Sex:

Male Female

* First name:

Surname:

* Email address:

* Confirm email address:

1) What age are you:

2) Year when first diagnosed:

3) What is your current status:

4) Are you currently taking medication for your RA?


Yes	No

5) Who prescribed your current medication?


GP	Consultant

6) How many times has your medication been changed by your GP/consultant?


1	2	3	4	5

7) Do you still experience pain even though you take medication?


Yes	No

8) How many days do you experience pain each week?


1	2	3	4	5+

9) Please rate, on a scale of 1 to 5 (1 = does not impact at all, 5 = fully impacts) the extent to which your RA negatively impacts on your undertaking the following:

Socialising and meeting new people
1	2	3	4	5

Going on holidays/choosing holiday destinations
1	2	3	4	5

Shopping
1	2	3	4	5

Attending sporting/cultural/ entertainment events
1	2	3	4	5

10) How aware is the following of your condition? Please rate on a scale of 1 to 5 (1 = not at all aware, 5 = fully aware) Please mark "not applicable" where appropiate.

Your partner
1	2	3	4	5	n/a

Your family
1	2	3	4	5	n/a

Your friends
1	2	3	4	5	n/a

Your employer
1	2	3	4	5	n/a

Your co-workers/students in your class at school/college
1	2	3	4	5	n/a

11) Please rate, on a scale of 1 to 5 how well you feel you are coping with your condition right now (1 = very poorly; 5 = very well)


1	2	3	4	5

12) On what aspect(s) of your condition would you like more information? (tick as many as apply)

a.	Coping at Work
b.	Travelling
c.	Support Groups
d.	Managing Diets
e.	Weight Issues
f.	Remembering Medications
g.	Other (please state)

13) How did you find out about the rheumatoid arthritis clinic?

Search Engine eg. Google
My Doctor/Nurse
Friend/Colleague
Media

Tick this box if you would like to be informed of special services from this website to help you manage your condition

Tick this box if you would you like to find out more about Arthritis Ireland

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Rheumatoid arthritis questionnaire