Français

I Have Options

Treatment-Assessment Questionnaire

Take a few minutes and help yourself with our quick and easy Treatment-Assessment Questionnaire. Your results will be compiled in an easy-to-view one-page report to help you identify areas of concern and treatment options you may want to discuss with your physician or medical specialist. A personalized treatment assessment will be sent to your e-mail address immediately upon completion.

In just a few minutes, you can find out the different treatment options available for your condition.

If you are a caregiver for someone else, you can also complete this questionnaire.

IMPORTANT NOTE: THIS QUESTIONNAIRE AND THE RESULTING PERSONALIZED ASSESSMENT ARE NOT DIAGNOSTIC TOOLS AND DO NOT IN ANY WAY REPLACE THE EXPERTISE OF A QUALIFIED PHYSICIAN OR MEDICAL SPECIALIST.

PRIVACY NOTICE: WE RESPECT THE PRIVACY OF YOUR INFORMATION. WE, AND COMPANIES PROVIDING SERVICES TO US, WILL NOT COLLECT OR USE THE INFORMATION YOU PROVIDE FOR ANY REASON OTHER THAN TO CREATE THE PERSONALIZED ASSESSMENT. ALL INFORMATION ENTERED IS USED FOR THE SOLE PURPOSE OF CREATING THE PERSONALIZED ASSESSMENT AND IS DELETED ONCE THE ASSESSMENT IS SENT TO YOUR E-MAIL ADDRESS.

1. Which condition have you been diagnosed with?





2. How long ago were you diagnosed?





3. How old are you?





4. Are you male or female?

5. [If rheumatoid arthritis]1
How did your arthritis affect your ability to carry out your daily life this week?

Please enter 0 if you can always do it and have no difficulty with the task.
Enter 1 if you can usually do it, although you have some difficulty.
Enter 2 if you can sometimes do it, but you usually have much difficulty.
Enter 3 if you are unable to do it.

Dressing and Grooming: Are you able to:


Arising: Are you able to:

Eating: Are you able to:


Walking: Are you able to:

Please check any aids or devices that you generally use for any of the above activities:


Please check any categories for which you usually need help from another person:
How did your arthritis affect your ability to carry out these tasks this week?

Please enter 0 if you can always do it and have no difficulty with the task.
Enter 1 if you can usually do it, although you have some difficulty.
Enter 2 if you can sometimes do it, but you usually have much difficulty.
Enter 3 if you are unable to do it.

Hygiene: Are you able to:


Reach: Are you able to:


Grip: Are you able to:


Activities: Are you able to:


Please check any aids or devices that you generally use for any of the above activities:


Please check any categories for which you usually need help from another person:
How is your overall health?

In general, would you say that your overall health is:

Morning stiffness:

Are you stiff in the morning?

If yes, how long does the stiffness last?
Pain:

Please check a box to indicate how much pain you have had in the last week:

012345678910
None very severe
When you wake up in the morning, do you ache?
If yes, how long does your pain last?
Do you take anything for pain?

If yes, please specify: And its dosage:
Symptoms:

Have you had any of these symptoms today, this past week, this past month?
Please check each box that is applicable.

General:
Fever
Dizziness
Tiredness (fatigue)
Head, eyes, ears, nose, mouth, throat:
Blurred vision
Ringing in your ears
Hearing difficulties
Mouth sores
Dry mouth
Loss of or change in taste
Headache
Chest, lungs and heart:
Chest pain
Shortness of breath
Wheezing
Musculoskeletal:
Joint pain
Joint swelling
Leg or ankle swelling
Low back pain
Muscle pain
Neck pain
Weakness of muscles
Gastrointestinal tract:
Loss of appetite
Nausea
Heartburn
Indigestion
Pain in stomach area
Liver problems
Pain in lower abdomen
Diarrhea, severe and frequent
Constipation
Black or tarry stools
Vomiting
Neurological and psychological:
Sadness
Depression
Insomnia
Nervousness
Trouble thinking
Skin:
Easy bruising
Hives or welts
Itching
Rash
Are you pregnant?
Reference: 1. ARAMIS Health Assessment Questionnaire (HAQ). ARAMIS — Stanford University Medical Center website. Accessed October 10, 2008.
5. [If Ankylosing spondylitis]1

Please check the box that best represents your answer. All questions refer to the past week.

How would you describe the overall level of fatigue/tiredness you have experienced?
012345678910
None very severe
How would you describe the overall level of AS neck, back or hip pain you have had?
012345678910
None very severe
How would you describe the overall level of pain/swelling in joints other than neck, back or hips you have had?
012345678910
None very severe
How would you describe the overall level of discomfort you have had from any areas tender to touch or pressure?
012345678910
None very severe
How would you describe the overall level of morning stiffness you have had from the time you wake up?
012345678910
None very severe
How long does your morning stiffness last from the time you wake up?
012345678910
0 hours ½ hours 1 hours 1½ hours 2 hours+
Reference: 1. Garrett S, Jenkinson T, Kennedy LG et al. A new approach to defining disease in ankylosing spondylitis: the Bath Ankylosing Spondylitis Disease Index. J Rheumatol. 1994;21(12):2286-2291.
5. [If Crohn's disease]

Please check the box that best represents your answer.

How would you describe the overall level of fatigue/tiredness you have experienced over the past week?
012345678910
None very severe
Does your condition affect your ability to go about your daily activities?
How many days of work or school did you miss because of your symptoms in the past 6 months?


How many flares have you had this past year?

How many bowel movements are you experiencing per day, in the last 6 months?
Have you noticed blood in your stool in the last 6 months?
In the last 6 months which areas of your life have been negatively affected by your symptoms of CD?





5. [If ulcerative colitis]

Please check the box that best represents your answer.

How would you describe the overall level of fatigue/tiredness you have experienced over the past week?
012345678910
None very severe
Does your condition affect your ability to go about your daily activities?
How many days of work or school did you miss because of your symptoms in the past 6 months?


How many flares have you had this past year?

How many bowel movements are you experiencing per day, in the last 6 months?
Have you noticed blood in your stool in the last 6 months?
In the last 6 months which areas of your life have been negatively affected by your symptoms of UC?





5. [If plaque psoriasis]1
Over the last week, how itchy, sore, painful or stinging has your skin been?
Not at all A little A lot Very much
Over the last week, how embarrassed or self-conscious have you been because of your skin?
Not at all A little A lot Very much
Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden?
Not at all A little A lot Very much Not relevant
Over the last week, how much has your skin influenced the clothes you wear?
Not at all A little A lot Very much Not relevant
Over the last week, how much has your skin affected any social or leisure activities?
Not at all A little A lot Very much Not relevant
Over the last week, how much has your skin made it difficult for you to do any sports?
Not at all A little A lot Very much Not relevant
Over the last week, has your skin prevented you from working or studying?
Not relevant Yes No
If "no", over the last week how much has your skin been a problem at work or studying?
Not at all A little A lot Very much
Over the last week, how much has your skin created problems with your partner or with any of your close friends or relatives?
Not at all A little A lot Very much Not relevant
Over the last week, how much has your skin caused sexual difficulties?
Not at all A little A lot Very much Not relevant
Over the last week, how much of a problem has the treatment for your skin been, for example by making your home messy or by taking up time?
Not at all A little A lot Very much Not relevant

DLQI =

Reference: 1. Finlay AY et al. Epidemiology and Health Services Research Dermatology Life Quality Index: influence of an illustrated version. Br J Dermatol. 2003;148:279-284.
5. [If psoriatic arthritis]1
How did your arthritis affect your ability to carry out your daily life this week?

Please enter 0 if you can always do it and have no difficulty with the task.
Enter 1 if you can usually do it, although you have some difficulty.
Enter 2 if you can sometimes do it, but you usually have much difficulty.
Enter 3 if you are unable to do it.

Dressing and Grooming: Are you able to:


Arising: Are you able to:

Eating: Are you able to:


Walking: Are you able to:

Please check any aids or devices that you generally use for any of the above activities:


Please check any categories for which you usually need help from another person:
How did your arthritis affect your ability to carry out these tasks this week?

Please enter 0 if you can always do it and have no difficulty with the task.
Enter 1 if you can usually do it, although you have some difficulty.
Enter 2 if you can sometimes do it, but you usually have much difficulty.
Enter 3 if you are unable to do it.

Hygiene: Are you able to:


Reach: Are you able to:


Grip: Are you able to:


Activities: Are you able to:


Please check any aids or devices that you generally use for any of the above activities:


Please check any categories for which you usually need help from another person:
How is your overall health?

In general, would you say that your overall health is:

Morning stiffness:

Are you stiff in the morning?

If yes, how long does the stiffness last?
Pain:

Please check a box to indicate how much pain you have had in the last week:

012345678910
None Severe
When you wake up in the morning, do you ache?
If yes, how long does your pain last?
Do you take anything for pain?
If yes, please specify:
And its dosage:
Symptoms:

Have you had any of these symptoms today, this past week, this past month?
Please check each box that is applicable.

General:
Fever
Dizziness
Tiredness (fatigue)
Head, eyes, ears, nose, mouth, throat:
Blurred vision
Ringing in your ears
Hearing difficulties
Mouth sores
Dry mouth
Loss of or change in taste
Headache
Chest, lungs and heart:
Chest pain
Shortness of breath
Wheezing
Musculoskeletal:
Joint pain
Joint swelling
Leg or ankle swelling
Low back pain
Muscle pain
Neck pain
Weakness of muscles
Gastrointestinal tract:
Loss of appetite
Nausea
Heartburn
Indigestion
Pain in stomach area
Liver problems
Pain in lower abdomen
Diarrhea, severe and frequent
Constipation
Black or tarry stools
Vomiting
Neurological and psychological:
Sadness
Depression
Insomnia
Nervousness
Trouble thinking
Skin:
Easy bruising
Hives or welts
Itching
Rash
Are you pregnant?
Reference: 1. ARAMIS Health Assessment Questionnaire (HAQ). ARAMIS — Stanford University Medical Center website. Accessed October 10, 2008.
6. Does your condition affect your ability to go about your daily activities?
7. How many days of work or school did you miss because of your symptoms in the past month?



8. Have you experienced any of the following symptoms in the past month?

Please select all that apply.






9a. Which medication(s) are you currently taking?

Please select all that apply.







































9b. Which medication(s) have you taken in the past for your condition?

Please select all that apply.







































9c. Have you had surgery?
9c. Have you had bowel surgery?
9c. Have you had bowel surgery?
9p. Have you had surgery?
10. How satisfied are you that your current treatment regimen is controlling your symptoms?



11. How interested are you in learning about other treatment options?


12. How knowledgeable are you about your condition?


13. How knowledgeable are you about the available treatment options?


14. Please select which of the following statements is most representative of your attitude.
"I am willing to treat my condition aggressively with the latest medication."
"I prefer to wait and see how other people do on a new drug before I try it."
15. Please select which of the following statements is most representative of your attitude.
"I really trust my specialist's recommendations about medications, so I don't do much research."
"I'm the type of person who needs to do my own research about new medication options."


As a last step, please provide us with your name and e-mail address so that we can send you a personalized treatment-assessment report right away. Print out and use the assessment as a helpful reference when discussing your treatment goals and preferences with your specialist or family physician.

Name:
Email address:
Re-type email address:

© 2011 Janssen Inc. | Privacy | Legal Notice

This site is intended for Canadian audiences and is published by Janssen Inc. which is solely responsible for its contents.
Last updated: June, 2010