Rheumatoid Arthritis Chief Complaint Intake Form
Please provide information about your main rheumatoid arthritis concerns to help us better understand your current situation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Date of Intake
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is your main rheumatoid arthritis concern today?
*
When did your current symptoms begin?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which joints are currently affected?
*
Fingers
Wrists
Elbows
Shoulders
Knees
Ankles
Other
How severe is your joint pain today?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
How much do your symptoms affect your daily activities?
*
Not at all
Mildly
Moderately
Severely
Are you currently taking any medications for rheumatoid arthritis?
*
Yes
No
If yes, please list your current medications
Submit
Should be Empty: