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Chronic Care Programme Assessment Questionnaire
Chronic disease Systemic Lupus Erythematosus
Date
Member surname Initials
GetMed membership GetMed plan
nr
GetMed account nr Option
Patient surname Initials
Patient date of birth Dependant code
Doctor name Initials
Doctor practice Contact number
number
Assessment questions
1. In general, how does the patient Excellent Very Good Fair Poor
consider his or her health: (Mark good
one)
2. How much time during the past 2
weeks...
2.1. Was the patient discouraged None A little Some of Most All of
by his or her health problems? of the of the the time of the the
time time time time
2.2. Was the patient fearful about None A little Some of Most All of
his or her future health? of the of the the time of the the
time time time time
2.3. Was the patient’s health a None A little Some of Most All of
worry in his or her life? of the of the the time of the the
time time time time
2.4. Was the patient frustrated by None A little Some of Most All of
his or her health problems? of the of the the time of the the
time time time time
3. Please circle the number that No fatigue to Severe fatigue
describes the patient’s fatigue in 0 1 2 3 4 5 6
the past 2 weeks: (mark one)
4. Please circle the number that No shortness of breath to severe shortness of breath
describes the patient’s
shortness of breath in the past 2 0 1 2 3 4 5 6
weeks: (mark one)
5. Please circle the number below No pain to severe pain
that describes the patient’s in
the past 2 weeks: 0 1 2 3 4 5 6
6. During the past week how much 0 mins Less 30 to 60 1 to 3 More
total time (for the entire week) did than mins hrs than 3
the patient spend on each of the 30 hrs
following? (Please circle one mins
number for each question.)
6.1. Stretching or strengthening 0 1 2 3 4
exercises
6.2. Walk for exercise 0 1 2 3 4
6.3. Swimming or aquatic exercise 0 1 2 3 4
6.4. Bicycling (including stationary 0 1 2 3 4
exercise bikes)
6.5. Other aerobic exercise 0 1 2 3 4
equipment (Stairmaster,
rowing, skiing machine, etc.)
6.6. Other aerobic exercise 0 1 2 3 4
6.6.1. Specify type
7. For each of the following questions,
please choose the number that
corresponds to the patient’s
confidence that he or she can do
the tasks regularly at the present
time. From not at all confident to totally confident
7.1. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can keep
the fatigue caused by his or
her disease from interfering
with the things he or she wants
to do?
7.2. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can keep
the physical discomfort or pain
of his or her disease from
interfering with the things he or
she wants to do?
7.3. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can keep
the emotional distress caused
by his or her disease from
interfering with the things he or
she wants to do?
7.4. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can keep
any other symptoms or health
problems he or she has from
interfering with the things he or
she wants to do?
7.5. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can do the
different tasks and activities
needed to manage his or her
health condition so as to
reduce his or her need to see a
doctor?
7.6. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can do
things other than just taking
medication to reduce how
much his or her illness affects
his or her everyday life?
8. During the past 2 weeks, how
much... mark one
8.1. Has the patient’s health Not at Slightly Moderately Quite Almost
interfered with his or her all a bit totally
normal social activities with
family, friends, neighbours or
groups?
8.2. Has the patient’s health Not at Slightly Moderately Quite Almost
interfered with his or her all a bit totally
hobbies or recreational
activities?
8.3. Has the patient’s health Not at Slightly Moderately Quite Almost
interfered with his or her all a bit totally
household chores?
8.4. Has the patient’s health Not at Slightly Moderately Quite Almost
interfered with his or her all a bit totally
errands and shopping?
9. In the past 6 months, how many
times did the patient visit a doctor?
Do NOT include visits while in the times
hospital or the hospital emergency
room.
10. In the past 6 months, how many
times did the patient go to a times
hospital emergency/casualty room?
11. How many different times did the
patient stay in a hospital overnight times
or longer in the past 6 months?
12. How many total nights did the
patient spend in the hospital in the nights
past 6 months?
13. When was the patient diagnosed with > 3 years 1-3 years In the last
SLE? ago ago 12 months
14. Does the patient have skin Yes No
manifestations such as a butterfly rash,
discoid lesions or loss of hair?
15. Does the SLE affect the patient’s lungs? No Pleurisy or Restrictive
fluid build up lung disease
(effusion) with reduced
airflow
16. Does the SLE affect the patient’s heart? No Rhythm Heart failure
disturbances,
heart sac
affected
17. Was the patient ever admitted for SLE Never More than a Within the
symptoms or complications? year ago last 12
months
18. Has the patient been on oral cortisone Never More than a Within the
for SLE before? year ago last 12
months
19. How would you describe the patient’s Well Moderately Poorly
current symptoms? controlled well controlled
controlled
20. In terms of medication use would you Very Moderately Poor
describe the patient as: compliant compliant compliance
21. In terms of lifestyle adaptation would Very Moderately Poor
you describe the patient as: compliant compliant compliance
22. How would you describe the patient’s Well Moderately Poorly
current status? controlled well controlled
controlled
23. Has the patient been treated with Never More than a Within the
chronic drugs other than cortisone e.g. year ago last 12
Chloroquine? months
24. How would you assess the severity of Mild Moderate Severe
the condition?
For Office use
Reviewed by (please sign)
Date
25. In general, how does the patient Excellent Very Good Fair Poor
consider his or her health: (Mark good
one)
26. How much time during the past 2
weeks...
26.1. Was the patient discouraged None A little Some of Most All of
by his or her health problems? of the of the the time of the the
time time time time
26.2. Was the patient fearful about None A little Some of Most All of
his or her future health? of the of the the time of the the
time time time time
26.3. Was the patient’s health a None A little Some of Most All of
worry in his or her life? of the of the the time of the the
time time time time
26.4. Was the patient frustrated by None A little Some of Most All of
his or her health problems? of the of the the time of the the
time time time time
27. Please circle the number that No fatigue to Severe fatigue
describes the patient’s fatigue in
the past 2 weeks: (mark one) 0 1 2 3 4 5 6
28. Please circle the number that No shortness of breath to severe shortness of breath
describes the patient’s
shortness of breath in the past 2 0 1 2 3 4 5 6
weeks: (mark one)
29. Please circle the number below No pain to severe pain
that describes the patient’s in
the past 2 weeks: 0 1 2 3 4 5 6
30. During the past week how much 0 mins Less 30 to 60 1 to 3 More
total time (for the entire week) did than mins hrs than 3
the patient spend on each of the 30 hrs
following? (Please circle one mins
number for each question.)
30.1. Stretching or strengthening 0 1 2 3 4
exercises
30.2. Walk for exercise 0 1 2 3 4
30.3. Swimming or aquatic exercise 0 1 2 3 4
30.4. Bicycling (including stationary 0 1 2 3 4
exercise bikes)
30.5. Other aerobic exercise 0 1 2 3 4
equipment (Stairmaster,
rowing, skiing machine, etc.)
30.6. Other aerobic exercise 0 1 2 3 4
30.6.1. Specify type
31. For each of the following questions,
please choose the number that
corresponds to the patient’s From not at all confident to totally confident
confidence that he or she can do
the tasks regularly at the present
time.
31.1. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can keep
the fatigue caused by his or
her disease from interfering
with the things he or she wants
to do?
31.2. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can keep
the physical discomfort or pain
of his or her disease from
interfering with the things he or
she wants to do?
31.3. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can keep
the emotional distress caused
by his or her disease from
interfering with the things he or
she wants to do?
31.4. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can keep
any other symptoms or health
problems he or she has from
interfering with the things he or
she wants to do?
31.5. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can do the
different tasks and activities
needed to manage his or her
health condition so as to
reduce his or her need to see a
doctor?
31.6. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can do
things other than just taking
medication to reduce how
much his or her illness affects
his or her everyday life?
32. During the past 2 weeks, how
much... mark one
32.1. Has the patient’s health Not at Slightly Moderately Quite Almost
interfered with his or her all a bit totally
normal social activities with
family, friends, neighbours or
groups?
32.2. Has the patient’s health Not at Slightly Moderately Quite Almost
interfered with his or her all a bit totally
hobbies or recreational
activities?
32.3. Has the patient’s health Not at Slightly Moderately Quite Almost
interfered with his or her all a bit totally
household chores?
32.4. Has the patient’s health Not at Slightly Moderately Quite Almost
interfered with his or her all a bit totally
errands and shopping?
33. In the past 6 months, how many
times did the patient visit a doctor?
Do NOT include visits while in the times
hospital or the hospital emergency
room.
34. In the past 6 months, how many
times did the patient go to a times
hospital emergency/casualty room?
35. How many different times did the
patient stay in a hospital overnight times
or longer in the past 6 months?
36. How many total nights did the
patient spend in the hospital in the nights
past 6 months?
