Fehmida Zahabi, M.D
6300 Stonewood Dr. Suite 412 Plano, TX 75024

RAPID5 Multi Dimensional Health Assessment Questionaire(MDHAQ)

YOUR NAME:
Date of Birth:
Today's Date:
1. Please check (✔) the ONE best answer for your abilities at this time:
OVER THE PAST WEEK, were you able to:
Without
ANY
difficulty
With
SOME
difficulty
With
MUCH
difficulty
UNABLE to do
Dress yourself, including tying shoelaces, doing buttons?
0 1 2 3
Get in and out of bed?
0 1 2 3
Lift a full cup or glass to your mouth?
0 1 2 3
Walk outdoors on flat ground?
0 1 2 3
Wash and dry your entire body?
0 1 2 3
Bend down to pick up clothing from the floor?
0 1 2 3
Turn regular faucets on and off?
0 1 2 3
Get in and out of a car, bus, train or airplane?
0 1 2 3
Walk two miles?
0 1 2 3
Participate in sports and games as you would like?
0 1 2 3

2. How much pain have you had because of your condition OVER THE PAST WEEK?
    Please indicate below how severe your pain has been:
NO PAIN
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10
PAIN AS BAD AS IT COULD BE
3. Please place a check () in the appropriate spot to indicate the amount of the pain you are     having today in each of the joint areas listed below:
  None Mild Moderate Severe
LEFT FINGERS 0 1 2 3
LEFT WRIST 0 1 2 3
LEFT ELBOW 0 1 2 3
LEFT SHOULDER 0 1 2 3
LEFT HIP 0 1 2 3
LEFT KNEE 0 1 2 3
LEFT ANKLE 0 1 2 3
LEFT TOES 0 1 2 3
NECK 0 1 2 3
  None Mild Moderate Severe
RIGHT FINGERS 0 1 2 3
RIGHT WRIST 0 1 2 3
RIGHT ELBOW 0 1 2 3
RIGHT SHOULDER 0 1 2 3
RIGHT HIP 0 1 2 3
RIGHT KNEE 0 1 2 3
RIGHT ANKLE 0 1 2 3
RIGHT TOES 0 1 2 3
BACK 0 1 2 3
4. Considering all the ways in which illness and health conditions may affect you at this time, please indicate below how you are doing:
VERY
WELL
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10
VERY
POORLY
DO NOT WRITE BELOW THIS - FOR DOCTORS USE ONLY - MD Global
VERY WELL
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10
VERY POORLY
FN 0-10
1-0.3
2-0.7
3-1.0
4-1.3
5-1.7
6-2.0
7-2.3
8-2.7
9-3.0
10-3.3
11-3.7
12-4.0
13-4.3
14-4.7
15-5.0
16-5.3
17-5.7
18-6.0
19-6.3
20-6.7
21-7.0
22-7.3
23-7.7
24-8.0
25-8.3
26-8.7
27-9.0
28-9.3
29-9.7
30-10
PN 0-10
PTGL 0-10
RAPID3 0-30
JT CT 0-10
1-0.2
2-0.4
3-0.6
4-0.8
5-1.0
6-1.3
7-1.5
8-1.7
9-1.9
10-2.1
11-2.3
12-2.5
13-2.7
14-2.9
15-3.1
16-3.3
17-3.5
18-3.8
19-4.0
20-4.2
21-4.4
22-4.6
23-4.8
24-5.0
25-5.2
26-5.4
27-5.6
28-5.8
29-6.0
30-6.3
31-6.4
32-6.7
33-6.9
34-7.1
35-7.3
36-7.5
37-7.7
38-7.9
39-8.1
40-8.3
41-8.5
42-8.8
43-9.0
44-9.2
45-9.4
46-9.6
47-9.8
48-10
RAPID4 0-40
MDGL: 0-10
RAPID5 0-50
5. Please check () if you have experienced any of the following over the last month:
Fever
Weight Gain (>10 lbs)
Weight Loss (<10 lbs)
Feeling sickly
Headaches
Unusual fatigue
Swollen glands
Loss of appetite
Skin rash or hives
Unusual bruising or bleeding
Othe skin problems
Loss of hair
Dry Eyes
Other Eye problems
Problem with hearing
Ringing in the ears
Stuffy nose
Sores in the mouth
Dry mouth
Problem with smell or taste
Lump in your thorat
Cough
Shortness of breath
Wheezing
Pain in the chest
Heart pounding(palpitations)
Trouble swallowing
Heartburn or stomach gas
Stomach pain or cramps
Nausea
Vomiting
Constipation
Diarrhea
Dark or bloody stools
Problem with urination
Gynecological(Female) problems
Dizziness
Losing your balance
Muscle pain, aches, or cramps
Muscle weakness
Paralysis of arms or legs
Fainting spells
Numbness or tingling of arms or legs
Swelling of hands
Swelling of ankles
Swelling in other joints
Joint pain
Back pain
Neck pain
Use of drugs not sold in stores
Smoking cigarettes
More than two alchohlic drinks per day
Depression - feeling blue
Anxiety - feeling nervous
Problem with thinking
Problem with memory
Problem with sleeping
Sexual problems
Burning in sex organs
Problem with social activities
6.When you awakened in the morning OVER THE LAST WEEK, did you feel stiff? No Yes If "No" please go to Item 7. If "Yes", please indicate the number of minutes , or hours until you are as limber as you will be for the day.

7.How do you feel TODAY compared to ONE WEEK AGO? Please check() only one.
(1). Much Better ,(2). Better ,(3). the Same ,(4). Worse (5). Much Worse than one week ago.

8.How often do you exercise aerobically (sweating, increase heart rate, shortness of breath) for atleast one-half hour(30 minutes)? Please check() only one. 3 or more times a week (3)     1-2 times per month (1)
1-2 times per week (2)     Do not exercise regularly (0)     Cannot exercise due to disability/ handicap (9)

9. How much of a problem has UNUSAUL fatigue or tiredeness been for you OVER THE PAST WEEK?

FATIGUE IS NO PROBLEM FATIGUE IS   A MAJOR PROBLEM
0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10

10. Over the last 6 months have you had: [Please Check()]

No Yes    An Operation
No Yes    Inpatient hospitalization
No Yes    a new illness, accident or truma
No Yes    An important new symptom
No Yes    Side effect(s) of any drug
No Yes    Smoke cigarettes regularly.
No Yes    Change(s) of arthritis drugs or other drugs
No Yes    Change(s) of address
No Yes    Change(s) of marital status
No Yes    Change job or work duties, quit work, retired
No Yes    Change of medical insurance, Medicare, etc.
No Yes    Change of primary care or other doctor

Please explain any "Yes" answer below, or indicate any other health matter that affects you:

SEX: Female, Male    ETHNIC GROUP: Asian, Black, Hispanic, White, Other

Your Occupation Circle the number of years of school you have completed:
1 2 3 4 5 6 7 8 9 10

Work Status: Full time Part time Disabled 11 12 13 14 15 16 17 18 19 20
Homemaker Self-Employed Retired
Seeking Work Other Record Your weight: lbs. height: inches
Your Name Date of Birth Todat's Date
Thank you for completing this questionnaire to help keep track of your medical care.
Fehmida Zahabi, M.D
6300 Stonewood Dr. Suite 412 Plano, TX 75024

Medication List For: Date

 
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