Page 1 of 2

Childhood Health Assessment Questionnaire - For adolescents to complete

Personal Details

First name *
Please enter child's first name

Middle name
Invalid Input

Surname *
Please enter child's surname

Date of Birth *
/ / Please provide date of birth

GP Surgery
Invalid Input

GP Name
Invalid Input

Ethnicity *
Please enter child's ethnicity

Address line 1 *
Please enter first line of child's address

Address line 2 *
Please enter second line of child's address

Address line 3
Invalid Input

Town
Invalid Input

Postcode *
Please enter child's postcode

Contact details

Mobile Phone No
Please input valid mobile phone number

Home Phone No
Please input valid home phone number

Work Phone No
Please input valid work phone number

Email address *
Please enter email address

Preferred Contact Method *
Please enter preferred method of contact

Questionnaire

We are interested in hearing how your illness affects your ability to function in daily life. In the following questions, please tick the one response which best describes your usual activities OVER THE PAST WEEK. ONLY NOTE THOSE DIFFICULTIES OR LIMITATIONS WHICH ARE DUE TO ILLNESS.
In the end, please go back and check once again that every item has been answered.

Dressing & Personal Care

Are you able to dress, including tying shoelaces and doing buttons? *

Please select one answer

Are you able to shampoo your hair? *

Please select one answer

Are you able to remove socks? *

Please select one answer

Are you able to cut fingernails? *

Please select one answer

Getting Up

Are you able to stand up from a low chair or floor? *

Please select one answer

Are you able to get in and out of bed *

Please select one answer

Eating

Are you able to cut your own meat? *

Please select one answer

Are you able to lift a cup or glass to your mouth? *

Please select one answer

Are you able to open a new cereal box? *

Please select one answer

Walking

Are you able to walk outside on flat ground? *

Please select one answer

Are you able to climb up five steps? *

Please select one answer

Hygiene

Are you able to wash and dry your entire body? *

Please select one answer

Are you able to take a bath (get in and get out)? *

Please select one answer

Are you able to get on and off the toilet? *

Please select one answer

Are you able to brush your teeth? *

Please select one answer

Are you able to comb or brush your hair? *

Please select one answer

Reach

Are you able to reach and get down a heavy object such as a large game or books from just above your head? *

Please select one answer

Are you able to bend down to pick up clothing or a piece of paper from the floor? *

Please select one answer

Are you able to pull on a jumper over your head? *

Please select one answer

Are you able to turn your neck to look back over your shoulder *

Please select one answer

Grip

Are you able to write with pen or pencil? *

Please select one answer

Are you able to open car doors? *

Please select one answer

Are you able to open jars which have been previously opened? *

Please select one answer

Are you able to turn taps on and off? *

Please select one answer

Are you able to push open a door when you have to turn a door knob? *

Please select one answer

Activities

Are you able to run errands and shop? *

Please select one answer

Are you able to get in an out of a car or school bus? *

Please select one answer

Are you able to ride a bike or a tricycle? *

Please select one answer

Are you able to do household chores eg wash dishes, take out rubbish, hoovering, gardening, make bed, clean room? *

Please select one answer

Are you able to run? *

Please select one answer

Aids or Devices

Please tick any AIDS or DEVICES that you usually use for any of the above activities:

Invalid Input

Help Required

Please tick any categories for which you usually need help from another person BECAUSE OF PAIN OR ILLNESS:

Invalid Input

Pain

How much pain do you think you have had IN THE PAST WEEK?
This is on a scale of 0 to 100 where 0 = No Pain and 100 = Very severe pain
Invalid Input

General Evaluation

Considering all the ways that arthritis affects your, rate how you are doing.
This is on a scale of 0 to 100 where 0 = Very well and 100 = Very poor
Invalid Input