Basic Information
Welcome to the Juvenile Idiopathic Arthritis Symptom Assessor.
The following series of questions will ask about your condition, medical history, and the medications you are taking. At the conclusion of this process, you will be provided a PDF file to download and print that you can bring to your rheumatologist or physician at your next visit.
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Date of Birth
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Gender
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Region
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Year you were diagnosed with JIA
Would you like to create an account?
If you would like us to remember your answers, please create an account. This will make it a lot faster to complete future assessments.
Account Login
Please login to your account. Forgot your password?
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E-mail
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Password
Create New Account
Input your e-mail and password to create an account that will save your history.
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E-mail Address
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Password
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Repeat Password
Your personal information will be kept confidential. Please see our privacy policy.
DMARDs
Please click on any medications that you are taking on the list below.
Biologics
Please click on any medications that you are taking on the list below.
Corticosteroids
Please click on any medications that you are taking on the list below.
NSAIDs
Please click on any medications that you are taking on the list below.
Please provide your medication dosages
For the following medications, please provide your dosage information and how frequent you take it.
Additional Information
Please answer the following additional questions for Prednisone:
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When did you have your last bone density test?
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Are you taking vitamin D?
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Are you taking Calcium?
Are you using any other medications?
Have you been using any other medications than those listed?
For each other medication, please list: medication + dosage + how often
Experiencing any new problems with your medications?
Have you been experiencing any new problems with your medications since your last visit? If you are not entirely sure then choose yes, you will be asked to provide further details.
Health Changes Since Last Visit
Since the last time you visited your rheumatologist, have you...
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Had any infections?
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Had any fevers?
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Been prescribed antibiotics?
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When was your last blood test?
Eyes Health
Please answer the following questions as related to your eyes:
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In the last year, how often did you get your eyes examined?
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Have you seen an eye doctor since your last visit?
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Are you using any eye drops?
Any major health changes since your last visit?
Examples of major health changes can include: being sick or diagnosed with a new disease, having surgery, and any health issues requiring a hospital visit.
Any tests or procedures since your last visit?
Examples of tests or procedures may include xrays, MRI, joint injections, etc.
Any major life changes since your last visit?
Examples include highly stressful or emotional situations such as: the death of a family member, friend, or pet; job loss; major career changes; or even a big move.
Upper Torso & Arms (Front Facing)
Click where you are experiencing pain or swelling in the diagram below.
Legs (Front Facing)
Click where you are experiencing pain or swelling in the diagram below.
Upper Torso & Arms (Backside)
Click where you are experiencing pain or swelling in the diagram below.
Legs (Backside)
Click where you are experiencing pain or swelling in the diagram below.
Hands
Click where you are experiencing pain or swelling in the diagram below.
Feet
Click where you are experiencing pain or swelling in the diagram below.
Childhood Health Assessment Questionnaire
We are interested in learning how your illness affects your ability to function in daily life.
In the following categories of questions, please check the one response which best describes your usual activities (averaged over an entire day). Please only note those difficulties or limitations that are due to illness.
Note for Parents: If most children at your child's age are not expected to do a certain activity, please choose "Not Applicable". For example, if your child has difficulty in doing a certain activity or is unable to do it because they are too young but not because they are restricted by illness, please mark it as "Not Applicable".
Dressing & Grooming
Check the response which best describes your usual activities (averaged over an entire day).
How difficult is it for you to...
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Dress, including tying shoelaces and doing buttons?
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Shampoo your hair?
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Remove socks?
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Cut fingernails?
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For the above activities, do you require any aids or devices?
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For the above activities, do you require any assistance from another person because of your illness?
Arising
Check the response which best describes your usual activities (averaged over an entire day).
How difficult is it for you to...
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Stand up from a low chair or floor?
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Get in and out of bed or stand up in crib?
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For the above activities, do you require any aids or devices?
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For the above activities, do you require any assistance from another person because of your illness?
Eating
Check the response which best describes your usual activities (averaged over an entire day).
How difficult is it for you to...
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Cut your own food?
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Lift a cup or glass to mouth?
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Open a new cereal box?
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For the above activities, do you require any aids or devices?
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For the above activities, do you require any assistance from another person because of your illness?
Walking
Check the response which best describes your usual activities (averaged over an entire day).
How difficult is it for you to...
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Walk outdoor on flat ground?
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Climb up five steps?
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For the above activities, do you require any aids or devices?
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For the above activities, do you require any assistance from another person because of your illness?
Hygiene
Check the response which best describes your usual activities (averaged over an entire day).
How difficult is it for you to...
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Wash and dry your entire body?
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Take a tub bath (get in & out of tub)?
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Get on and off the toilet or potty-chair?
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Brush teeth?
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Wash / Comb / Brush hair?
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For the above activities, do you require any aids or devices?
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For the above activities, do you require any assistance from another person because of your illness?
Reach
Check the response which best describes your usual activities (averaged over an entire day).
How difficult is it for you to...
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Reach and get down a heavy object such as a large game or books from just above your head?
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Bend down to pick up clothing or a piece of paper from the floor?
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Pull on a sweater over your head?
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Turn neck to look back over shoulder?
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For the above activities, do you require any aids or devices?
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For the above activities, do you require any assistance from another person because of your illness?
Grip
Check the response which best describes your usual activities (averaged over an entire day).
How difficult is it for you to...
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Write or scribble with pen or pencil?
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Open car doors?
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Open jars that have been previously opened?
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Turn faucets on and off?
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Push open a door when he/she has to turn a door knob?
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For the above activities, do you require any aids or devices?
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For the above activities, do you require any assistance from another person because of your illness?
Activities
Check the response which best describes your usual activities (averaged over an entire day).
How difficult is it for you to...
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Run errands and shop?
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Get in and out of car or toy car or school bus?
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Ride bike or tricycle?
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Do household chores (e.g. wash dishes, take out trash, vacuuming, yard work, made bed, clean room)?
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Run and play?
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For the above activities, do you require any aids or devices?
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For the above activities, do you require any assistance from another person because of your illness?
Childhood Assessment Questionaire
We'd like to know how you have been feeling and how your life has been impacted by pain in the last week:
Activity Scales
Please answer the following questions as related to your arthritis:
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For how many hours does your morning stiffness last from the time you wake up?
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How much of a problem has unusual fatigue or tiredness been for you over the past week? How much of a problem has unusual fatigue or tiredness been for you over the past week?
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How much of a problem has sleeping been for you over the past week? How much of a problem has sleeping been for you over the past week?
Quality of My Life
Some of the kids who come to see us feel that their life is not that great, while others think that their life is O.K. How about you?
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Since the last time I was here my life is…
Positive Changes
What has changed for the better since you started treatment?
Are you able to do things you couldn't do before, or have less pain?
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Discuss With Doctor
Is there anything that you would you like to discuss with your doctor at your next appointment?
Your assessment is Complete!
Your answers will be very helpful to your doctor on your next visit. Please bring the following PDF document to your next appointment.
Download PDF
