Physical abilities Please make a selection for all questions.

Are you able to:

1  Dress yourself, including shoelaces and buttons?

2  Get in and out of bed?

Physical abilities Please make a selection for all questions.

Are you able to:

Pain assessment

0No pain

10Pain as bad
as it could be

Personal assessment

0Very well

10Very poorly


                Score Description

1 to 3:

Near Remission


4 to 6:




7 to 12:




13 to 30:




Want to understand how your score is calculated? Learn more here >

Thinking about how RA impacts your life before your appointment can help you spend more time discussing treatment goals with your rheumotologist

Please provide appropriate value in each field's default value property as per Analytics Tech Specs

Form Name:

Form Category:

Account Management, Contact, Interactions, Quiz, Registration, Services


Form Sub-Category:

Password Resets, Login, Profile, Representative, Contact Us, Polls, Social Share, Doctor Discussion Guide, Dosing Guide, Symptom Checker, Knowledge Assessment, Event, More Info, Sign Up, Saving Card, Benefit Verification, Benefit Enrollments, Medical Exception, Injection Form, Share a Story

Form MVA Name:

Form MVA Type:

Download, Form, Link, Share, Tool, Video

Form MVA Tier:

Form MVA Category:

Savings Card, Insurance, Symptom Journal, Test Score Tracker, Condition Information, Doctor Discussion Guide, Dosing Information, Enrollment Form, Flashcard, Medical Exception, Patient Counseling Guide, Savings Card, Symptom Journal, Doctor Discussion Guide, Doctor Search, Dosage Calculator, Enroll, Med Reminders, Quick Poll, Resource Request, Symptom Quiz, UGC Submission, Contact Rep, Savings Card, Social Share, App Store, More Info, Patient Resources, Share Information, Share Results, Submit a Story, Assessment Tool, Benefits Verification, Carousel, Initiation, Myth versus Fact, Workaround Quiz, Formulary Tool, Image Expand, Medical Exception, Q And A, Slider, Administration Instructions, Condition Information, Insurance, Inventory, Mechanism of Action, Patient Story, Product Overview, Program Overview, Injection Training, Other


Form PII Field Names for Masking: