RAPID3 Questionnaire
this questionnaire takes about five minutes only
Please enter a nickname so we can identify your responses when we check them later in the visit (do NOT use your full name): *
Your answer
Section A: Check symptoms in the last week:
General and Endocrine:
Skin, Allergy and Joints:
Head and neck:
Chest and Heart:
Stomach/bowel:
Kidneys and Reproductive:
Nervous System/Psychiatric:
Section B: Over the LAST WEEK, were you able to:
(must have EXACTLY ONE answer to each question)
dress yourself, including shoe laces and buttons *
Get in and out of bed *
Lift a full cup or glass to your mouth *
Walk outdoors on flat ground *
Wash and dry your entire body *
Bend down to pick up clothing on the floor *
Turn regular faucets on and off *
Get in and out of the car, bus, or train *
Walk two miles or three kilometers if you wish *
Participate in recreational activities and sports, as you would like, if you wish *
Are your joints particularly stiff in the morning and for how long? *
How much pain have you had because of your condition over the PAST WEEK? *
none
max
Considering all the ways in which illness and health may affect you at this time, please indicate below how you are doing: *
good
bad
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service