Sample questionnaire (general)

• Author: Scott M. Riemer/Jennifer L. Hess
• Pages: 215-222

A - 19 7 Appendix: Sample Documents Form 4

FORM 4 SAMPLE QUESTIONNAIRE (GENERAL)

RESIDUAL FUNCTIONAL CAPACITY QUESTIONNAIRE

Re: _____________________________ (Name of Patient)

Patient’s Date of Birth:

Please answer the following questions concerning your patient’s autoimmune dis-

order(s) and other medical impairments. Please attach a copy of your most recent



 

Frequency of visits:

2. Primary diagnosis:

3. Other diagnoses:

4. Prognosis:

5. Have your patient’s impairments lasted or can they be expected to last at least

  

   

If yes, please describe your patient’s history of fatigue:

7. Does your patient have pain   

a. Please characterize the severity of your patient’s pain:

___mild ___ moderate ___ severe

b. Identify the location and frequency of your patient’s pain by marking or

shading the relevant areas of the body and labeling C for constant, F for

frequent, and I for intermittent: