Questionnaire - AIMS2

8/7/2019 Questionnaire - AIMS2

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of the originatorArthritis Rheum 35:1-10, 1992.

t Address: Robert F. Meenan MD, MPHThe Arthritis CenterBoston University School of MedicineConte Building80 East Concord StreetBoston, MAUSA 02118-2394617-638-5226

e check (X) the most appropriate answer for each question.

PAST MONTH ...All

Days(1)

MostDays(2)

SomeDays(3)

FewDays(4)NoDays(5)

1. How often were you physically able to drive acar or use pUblic transportation?2. How often were you out of the house for at leastpart of the day?3. How often were you able to do errands in theneighborhood? 4. How often did someone have to assist you to get

around outside your home? 5. How often were you in a bed or chair for most

or all of the day?AIMS

All Most Some Few NoDays Days Days Days DaysPAST MONTH ... (1 ) (2) (3) (4) (5)

6. Did you have trouble doing vigorous activitiessuch as running, lifting heavy objects, orparticipating in strenuous sports?

7. Did you have trouble either walking severalblocks or climbing a few flights of stairs?8. Did you have trouble bending, lifting, orstooping?9. Did you have trouble either walking one block

or climbing one flight of stairs?you unable to walk unless assisted by

another person or by a cane, crutches, orwalker?AIMS2 Contin


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please check (X) the most appropriate answer for each question.These questions refer to HAND AND FINGER FUNCTION.

DURING THE PAST MONTH ...11. Could you easily write with a pen or pencil?12. Could you easily button a shirt or blouse?13. Could you easily turn a key in a lock?14. Could you easily tie a knot or a bow?15. Could you easily open a new ja r of food?

AllDays(1)

MostDays(2)

SomeDays(3)FewDays(4)

NoDays(5)

AIMSThese questions refer to ARM FUNCTION.

All Most Some Few NoDays Days Days Days DaysDURING THE PAST MONTH ... (1) (2) (3) (4) (5)

16. Could you easily wipe your mouth with anapkin?17. Could you easily pu t on a pullover sweater?18. Could you easily comb or brush your hair?19. Could you easily scratch your low back withyour hand?20. Could you easily reach shelves that were above

your head?

These questions refer to SELF-CARE TASKS. AIMS

DURING THE PAST MONTH ... Always(1 )VeryOften(2) Sometimes(3)

AlmostNever(4) Never(5)21. Did you need help to take a bath or shower?22. Did you need help to get dressed?23. Did you need help to use the toilet?24. Did you need help to get in or out of bed?

These questions refer to HOUSEHOLD TASKS. AIMS

DURING THE PAST MONTH . . . Always(1 )VeryOften(2) Sometimes(3)

AlmostNever(4) Never(5)25. I f you had the necessary transportation,could you go shopping for groceries withouthelp?

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Please check (X) the most appropriate answer for each question.26. I f you had kitchen facilities, could youprepare your own meals without help?27. I f you had household tools and appliances,could you do your own housework without

help?28. If you had laundry facilities, could you do

your own laundry without help?AIMThese questions refer to SOCIAL ACTIVITY.

All Most Some Few NoDays Days Days Days DaysDURING THE PAST MONTH ... (1) (2) (3) (4) (5)29. How often did you get together with friends or

relatives?30. How often did you have friends or relatives overto your home?31. How often did you visit friends or relatives at

their homes? 32. How often were you on the telephone with close

friends or relatives?33. How often did you go to a meeting of a church,club, team, or other group?

These questions refer to SUPPORT FROM FAMILY AND FRIENDS.AIM

DURING THE PAST MONTH ... Always(1 )VeryOften(2)

Sometimes(3 )

AlmostNever(4) Never(5)34. Did you feel that your family or friendswould be around i f you needed assistance?35. Did you feel that your family or friends were

sensitive to your personal needs?36. Did you feel that your family or friends wereinterested in helping you solve problems?37. Did you feel that your family or friendsunderstood the effects of your arthritis?

These questions refer to ARTHRITIS PAIN. AIM

DURING THE PAST MONTH ... Severe(1 ) Moderate(2) Mild(3) Very Mild(4) None(5)38. How would you describe the arthritis painyou usually had?

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Please check (X) the most appropriate answer for each question.All

Days(1)

MostDays(2)

SomeDays(3)

FewDays(4)

NoDays(5 )

39. How often did you have severe pain from yourarthritis?40. How often did you have pain in two or more

joints at the same time?41. How often did your morning stiffness last morethan 1 hour from the time you woke up?42. How often did your pain make it difficult foryou to sleep?

AIThese questions refer to WORK.

Paid House Schoolwork work work Unemployed Disabled RetiredDURING THE PAST MONTH ... (1 ) (2 ) (3) (4) (5) (6)

43. What has been your main form ofwork?If you answered unemployed, disabled, or retired, please skip the next four questions and go to the next page.

All Most Some Few NoDays Days Days Days DaysDURING THE PAST MONTH ... (1 ) (2 ) (3 ) (4) (5)44. How often were you unable to do any paidwork, house work, or school work?45. On the days that you did work, how often did

you have to work a shorte r day?46. On the days that you did work, how often wereyou unable to do your work as carefully andaccurately as you would like?47. On the days tha t you did work. how often didyou have to change the way your paid work,

housework, or school work is usually done?

These questions refer to LEVEL OF TENSION. AI

DURING THE PAST MONTH ... Always(1 )VeryOften(2 )

Sometimes(3 )

AlmostNever(4) Never(5)48. How often have you felt tense or highstrung?49. How often have you been bothered by

nervousness or your nerves?

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Please check (X ) the most appropriate answer for each question.50. How often were you able to relax withoutdifficulty?5L How often have you felt relaxed and free oftension?52. How often have you felt calm and peaceful?

AIM

These questions refer to MOOD.

DURING THE PAST MONTH ... Always(1 )VeryOften(2 )

Sometimes(3)AlmostNever(4) Never(5)

53. How often have you enjoyed the things youdo?54. How often have you been in low or very lowspirits?55. How often did you feel that nothing turnedou t the way you wanted it to?56. How often did you feel that others would bebetter off if you were dead?57. How often did you feel so down in the

dumps that nothing would cheer you up?AlMThese questions refer to satisfaction with each health area.

NeitherVery Somewhat Satisfied Nor Somewhat VerySatisfied Satisfied Dissatisfied Dissatisfied DissatisfiedDURING THE PAST MONTH ... (1) (2) (3) (4) (5)

58. How satisfied have you beenwith each of these areas of yourhealth?

MOBILITY LEVEL(example: do errands)(example: climb stairs)

AND AND FINGER FUNCTION(example: tie a bow)RM FUNCTION(example: comb hair)

(example: take bath)

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TASKS

FAMILY

PAINjoint pain)

OF TENSION

down in dumps)AIMS

on each area of health.Due Partly

Due Due to Arthritis Due DueNot a Entirely Largely and Partly Largely EntirelyProblem to Other to Other to Other to My to My

for Me Causes Causes Causes Arthritis ArthritisPAST MONTH ... (0 ) (1) (2) (3) (4) (5)much of your problem ineach area of health was due toyour arthritis?do errands)

M FUNCTION

TASKS

ACTIVITYFAMILY

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joint pain)ple: reduce hours)

OF TENSION

down in dumps)

have now answered questions about different AREAS OF YOUR HEALTH. These areas are listed below. Plup to THREE AREAS in which you would MOST LIKE TO SEE IMPROVEMENT. please read all 12

of health choices before making your decision:checkblank

AREAS OF HEALTH THREE AREAS FOR IMPROVEMENT

M FUNCTION

TASKS

FAMILY

RTHRITIS PAINjOint pain)

EVEL OF TENSION

down in dumps) Please make sure that you have checked no more than THREE AREAS for improvement.

AIMS2 Contin

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Questionnaire - AIMS2