The answers you provide will be used only to create your personal report. They will not be shared with anyone else, or saved on any computers unless you choose to save the report on yours. Read more about our commitment to privacy.

RAlly Guest Questionnaire

Age, Gender and Diagnosis
What is your age?  
Are you a woman or a man ?
What is your primary rheumatic disease diagnosis? (For example, lupus, rheumatoid arthritis, osteoarthritis, etc.)
Joint Pain
Please indicate below the amount of pain and/or tenderness you have had over the PAST 7 DAYS in each JOINT listed below. Click the box that best describes your pain or tenderness. Be sure to mark both right side and left side. If you have had no pain or tenderness in a particular JOINT, click "None".
Joints NoneMildModerateSevere
Shoulder, Lt.
Shoulder, Rt.
Elbow, Lt.
Elbow, Rt.
Wrist, Lt.
Wrist, Rt.
Hand Knuckles, Lt.
Hand Knuckles, Rt.
Finger Knuckles, Lt.
Finger Knuckles. Rt.
Hip, Lt.
Hip, Rt.
Knee, Lt.
Knee, Rt.
Ankle, Lt.
Ankle, Rt.
Ball of Foot, Lt.
Ball of Foot, Rt.
Heel, Lt.
Heel, Rt.
Foot arch, Lt.
Foot arch, Rt.

Body Pain
Please indicate below the amount of pain and/or tenderness you have had over the PAST 7 DAYS in each of the BODY AREAS listed below. Click the box that best describes your pain or tenderness. If you have had no pain or tenderness in a particular BODY PART, click "None".
Other Body Areas NoneMildModerateSevere
Jaw, Lt.
Jaw, Rt.
Lower Back
Upper Back
Neck
Upper Arms, Lt.
Upper Arms, Rt.
Lower Arms, Lt.
Lower Arms, Rt.
Upper Leg, Lt.
Upper Leg, Rt.
Lower Leg, Lt.
Lower Leg, Rt.
Head
Chest
Abdomen

Clinical Health Assessment Questionnaire (CLINHAQ)
We are also interested in learning whether or not you are affected by pain because of your illness.
How much pain have you had because of your illness IN THE PAST WEEK? Click the box that best describes the severity of your pain on a scale of 0 - 100.
0100
No pain Severe Pain
We are interested in knowing about any problems that you may have been having with fatigue. How much of a problem has fatigue or tiredness been for you IN THE PAST WEEK? Click the box below that best describes the severity of your fatigue on a scale of 0 - 100.
0100
Fatigue is no problem Fatigue is a major problem
Are you able to: Without any difficultyWith some difficultyWith much difficultyUnable to do
Go up two or more flights of stairs?
Do outside work (such as yard work)?
Move heavy objects?
Lift heavy objects?
Wait in a line for 15 minutes?
Stand up from a straight chair?
Walk outdoors on flat ground?
Get on and off the toilet?
Reach and get down a 5 pound object (such as a bag of sugar) from just above your head?
Open car doors?
Considering ALL THE WAYS THAT YOUR ILLNESS AFFECTS YOU, RATE HOW YOU ARE DOING on the following scale. Click the box below that best describes how you are doing on a scale of 0 - 100.
0100
Very well Very poor

Your report results will be ready in approximately 50 seconds.