PAS Patient Form Clinical Calculator and Pathway

We are interested in learning how your illness affects your ability to function in daily life. Which best describes your usual abilities OVER THE PAST WEEK:

Dress yourself, including shoelaces and buttons?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Shampoo your hair?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Stand up from a straight chair?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Get in and out of bed?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Cut your meat?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Lift a full cup or glass to your mouth?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Open a new milk carton?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Walk outdoors on flat ground?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Climb up five steps?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Which, in any, aids or devices that you usually use for any of the above activities:

Cane

No Yes

Crutches

No Yes

Walker

No Yes

Wheelchair

No Yes

Built up or special utensils

No Yes

Special or built up chair

No Yes

Devices used for dressing (button hook, zipper pull, long handled shoe horn)

No Yes

Other

No Yes

Select each category for which you usually need HELP FROM ANOTHER PERSON:

Dressing and Grooming

No Yes

Arising

No Yes

Eating

No Yes

Walking

No Yes

Which best describes your usual abilities OVER THE PAST WEEK:

Wash and dry your body?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Take a tub bath?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Get on and off the toilet?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Reach and get down a 5 pound object (such as a bag of sugar) from just above your head?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Bend down to pick up clothing from the floor?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Open car doors?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Open jars which have been previously opened?

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do

Which, if any, aids or devices do you usually use for any of the above activities:

Bathtub bar

No Yes

Raised toilet seat

No Yes

Jar opener for jars previously opened

No Yes

Long-handled appliances for reach>

No Yes

Long-handled appliances in bathroom

No Yes

Other

No Yes

Select each category for which you usually need HELP FROM ANOTHER PERSON:

Hygiene

No Yes

Reach

No Yes

Gripping and Opening Things

No Yes

Errands and Chores

No Yes

How much pain have you had because of your illness in the past week? (0 - 10)

0 being no pain
10 being severe pain

Considering ALL THE WAYS THAT YOUR ILLNESS AFFECTS YOU, RATE HOW YOU ARE DOING on the following scale. (0 - 10)

0 being very well.
10 being very poor.

Source: Wolfe F, Michaud K, Pincus T. A composite disease activity scale for clinical practice, observational studies, and clinical trials: the patient activity scale (PAS/PAS-II). J Rheumatol. 2005;32(12):2410-5.

PAS Patient Form

With this form patients are able to indicate the difficulty in which usual daily abilities have become in the course of a week.

We are interested in learning how your illness affects your ability to function in daily life. Which best describes your usual abilities OVER THE PAST WEEK:

Which, in any, aids or devices that you usually use for any of the above activities:

Select each category for which you usually need HELP FROM ANOTHER PERSON:

Which best describes your usual abilities OVER THE PAST WEEK:

Which, if any, aids or devices do you usually use for any of the above activities:

Select each category for which you usually need HELP FROM ANOTHER PERSON:

Interpretation