HAQ Assessment Form – Rheumspect

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Fill out this simple form to assess how RA may be affecting your daily life, and share
the answers with your rheumatologist. He or she may find the information useful when
evaluating your condition and discussing treatment options.

THIS COLUMN FOR
PHYSICIAN USE ONLY

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Patient's Name

Date

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Please check the response that best describes
your usual abilities over the past week:

Highest score

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DRESSING & GROOMING-are you able to:

Dress yourself, including shoelaces and buttons? Shampoo your hair?

Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
Unable to do (3)

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ARISING-are you able to:

Stand up from a straight chair? Get in and out of bed?

Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
Unable to do (3)

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EATING-are you able to:

Cut your meat? Lift a full cup or glass to your mouth? Open a new milk carton?

Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
Unable to do (3)

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WALKING-are you able to:

Walk outdoors on flat ground? Climb up five steps?

Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
Unable to do (3)

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HYGIENE-are you able to:

Wash and dry your body? Get on and off the toilet?

Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
Unable to do (3)

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REACH-are you able to:

Reach and get down a 5-pound object (such as a bag of sugar) from above your head? Bend down to pick up clothing from the floor?

Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
Unable to do (3)

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GRIP-are you able to:

Open car doors? O Open previously opened jars? Turn faucets on and off?

Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
Unable to do (3)

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ACTIVITIES-are you able to:

Run errands and shop? Get in and out of a car? Do chores such as vacuuming or yard work?

Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
Unable to do (3)

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How much pain have you had because of your RA IN THE PAST WEEK:
Place a single vertical mark (|) on the line to indicate the severity of the pain.

Pain Score

TOTAL

NO PAIN 50 SEVERE PAIN
.........................................................................................................................
0 100

- Number of answered groups

To learn more about RA, visit RAdaily.com.

The Health Assessment Questionnaire (HAQ) Disability Index measures disability with the use of aids and devices. It is scored
on a scale of 0 to 3 units. A score of 0 indicates the lack of any measurable degree of disability, whereas a score of 3 means
that a patient is unable to perform all activities.

TOTAL HAQ Disability Index Score