Osteoarthritis Assessment Form
Please complete this form to help us assess your osteoarthritis symptoms and their impact on your daily life.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Which joints are affected by osteoarthritis? (Select all that apply)
*
Knee
Hip
Hand
Spine
Foot/Ankle
Other
How would you rate your average pain in the affected joint(s) over the past week?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst imaginable pain
10
0 is No pain, 10 is Worst imaginable pain
Please rate the severity of the following symptoms in the past week:
*
Rows
None
Mild
Moderate
Severe
Joint stiffness
1
2
3
4
Swelling
5
6
7
8
Reduced range of motion
9
10
11
12
Grinding or popping sensations
13
14
15
16
How much difficulty do you have with the following activities due to osteoarthritis?
*
Rows
No difficulty
Some difficulty
Moderate difficulty
Severe difficulty
Unable to do
Walking
17
18
19
20
21
Climbing stairs
22
23
24
25
26
Standing up from a chair
27
28
29
30
31
Getting in/out of a car
32
33
34
35
36
Household chores
37
38
39
40
41
How much has osteoarthritis interfered with your daily life in the past week?
*
Not at all
A little
Moderately
Severely
Have you used any of the following treatments for osteoarthritis? (Select all that apply)
Pain medication (oral/topical)
Physical therapy
Injections (corticosteroids, hyaluronic acid, etc.)
Surgery
Exercise
Other
Please describe any other symptoms or concerns related to your osteoarthritis.
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please rate your overall satisfaction with your current osteoarthritis management.
1
2
3
4
5
Submit Assessment
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