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By providing your personal and medical information, you acknowledge and agree that this information is being collected solely for medical purposes related to your healthcare treatment. We are committed to maintaining the confidentiality, integrity, and security of your information in accordance with the Health Insurance Portability and Accountability Act (HIPAA). Your medical information will not be used for any purpose other than to support your medical care and treatment. We will not share, disclose, or use your information outside of the direct medical needs of your healthcare services, unless required or permitted by law.
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Rheum One Survey One-Time Payment* This field is required."This one-time rheumatology survey is designed to provide personalized insights into your symptoms and needs. A small fee is required to ensure thorough, high-quality analysis. If you have any questions about the value of this service or payment options, we’re happy to help—just contact us at: TheTeam@Rheum1.org." Your information is not stored and will only be used to process the one-time payment.
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Your Name* This field is required.Please enter your legal name.
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Email* This field is required.We will use this email for Rheum One correspondence only. This is not for marketing purposes and you will not be contacted otherwise.
example@example.com
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Medical History* This field is required.Please select ONLY the answer that you or your family have been officially diagnosed with. Copyright © 2022. RheumOne, PLLC. All rights reserved
Self
Family
Both
None
Rheumatoid Arthritis
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Psoriatic Arthritis/Psoriasis
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Lupus/Connective Tissue Disease
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Ankylosing Spondylitis
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
PMS/DMS/Inflammatory Muscle Disease
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Graves' or Hashimoto Thyroiditis
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Gout
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Ulcerative colitis or Crohn's disease
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Generalized Osteoarthritis
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Rheumatoid Arthritis
Psoriatic Arthritis/Psoriasis
Lupus/Connective Tissue Disease
Ankylosing Spondylitis
PMS/DMS/Inflammatory Muscle Disease
Graves' or Hashimoto Thyroiditis
Gout
Ulcerative colitis or Crohn's disease
Generalized Osteoarthritis
Self
Row 0, Column 0
Family
Row 0, Column 1
Both
Row 0, Column 2
None
Row 0, Column 3
Self
Row 1, Column 0
Family
Row 1, Column 1
Both
Row 1, Column 2
None
Row 1, Column 3
Self
Row 2, Column 0
Family
Row 2, Column 1
Both
Row 2, Column 2
None
Row 2, Column 3
Self
Row 3, Column 0
Family
Row 3, Column 1
Both
Row 3, Column 2
None
Row 3, Column 3
Self
Row 4, Column 0
Family
Row 4, Column 1
Both
Row 4, Column 2
None
Row 4, Column 3
Self
Row 5, Column 0
Family
Row 5, Column 1
Both
Row 5, Column 2
None
Row 5, Column 3
Self
Row 6, Column 0
Family
Row 6, Column 1
Both
Row 6, Column 2
None
Row 6, Column 3
Self
Row 7, Column 0
Family
Row 7, Column 1
Both
Row 7, Column 2
None
Row 7, Column 3
Self
Row 8, Column 0
Family
Row 8, Column 1
Both
Row 8, Column 2
None
Row 8, Column 3
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Do you have pain?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
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Pain Type* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Muscle Pain
Joint Pain
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Pain Quality* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Ache/Sore
Throb
Burn
Sharp
Numbness/Tingling
None
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Joint pain constant or episodic?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Constant
Episodic
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Joint pain frequency* This field is required.How often does the symptom occur? Copyright © 2022. RheumOne, PLLC. All rights reserved
1-3 X per year
4-7 X per year
Greater than 7 X per year
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Joint pain duration* This field is required.How long does the symptom last? Copyright © 2022. RheumOne, PLLC. All rights reserved
Less than 24 hours
1-6 days
Greater than 6 days
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Joint pain location?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Hands
Feet
Body
Back
15
Back pain location?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Neck
Mid back
Lower back
None
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Joint pain hands: Use your mouse to draw an X or color in any areas that have joint pain. To reset and start over, click the "Clear" button below the image.* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
17
Joint pain feet: Use your mouse to draw an X or color in any areas that you have joint pain. To reset and start over, click the "Clear" button below the image.* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
18
Joint pain body: Use your mouse to draw an X or color in any areas that you have joint pain. To reset and start over, click the "Clear" button below the image.* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
19
Pain worsens at night?* This field is required.Does the pain worsen at night? Copyright © 2022. RheumOne, PLLC. All rights reserved
Yes
No
20
Joint swelling/ puffiness?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
21
Joint puffiness vs swelling?* This field is required.Please select a single choice that best matches your symptom. Copyright © 2022. RheumOne, PLLC. All rights reserved
Puffy Edema
Red hot joint swelling
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Swelling constant or episodic?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Constant
Episodic
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Swelling frequency?* This field is required.How often does the sympton occur? Copyright © 2022. RheumOne, PLLC. All rights reserved
1-3 X per year
4-7 X per year
Greater than 7 X per year
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Swelling duration?* This field is required.How long does the symptom last? Copyright © 2022. RheumOne, PLLC. All rights reserved
Less than 24 hours
1-6 days
Greater than 6 days
25
Red, hot and swollen location?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Hands
Feet
Body
Back
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Red, hot and swollen Hands: Use your mouse to draw an X or color in any areas that red, hot and swollen. To reset and start over, click the "Clear" button below the image.* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
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Red, hot and swollen feet: Use your mouse to draw an X or color in any areas that red, hot and swollen. To reset and start over, click the "Clear" button below the image.* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
28
Red, hot and swollen body: Use your mouse to draw an X or color in any areas that red, hot and swollen. To reset and start over, click the "Clear" button below the image.* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
29
Weakness?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
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I am unable to move due to______.* This field is required.Please select the most prevalent symptom. Copyright © 2022. RheumOne, PLLC. All rights reserved
Pain
Weakness
Does not apply
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Decreased ability to grip or grasp due to ______.* This field is required.Please select the most prevalent symptom. Copyright © 2022. RheumOne, PLLC. All rights reserved
Pain
Weakness
Does not apply
32
Do you need assistance to raise your arms overhead?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Yes
No
33
Do you need assistance to stand from a sitting position?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Yes
No
34
Do you experience muscle cramping?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Yes
No
35
Nose and/ or Mouth sores?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
36
Nose or mouth sores symptoms?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Bumps
Ulcers
None
37
Nose or mouth sores quality* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Painful
Not painful
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Miscarriages?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
39
How many miscarriages?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
1
2
3
4 or More
40
Miscarriage(s) occurred during which trimester?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
1st (1-12weeks)
2nd (13-24weeks)
3rd (25-36+weeks)
41
Neuropathy (Burn, Tingle, Numbness, Stabbing)* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
42
Neuropathy Location?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Hands
Feet
Legs
None
43
Liver Disease?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
44
Are you diagnosed with a liver disease listed below?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Fatty liver disease
Gallbladder
Cirrhosis
Other
None of these
45
Kidney Disease?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
46
Are you diagnosed with a kidney disease listed below?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Chronic Kidney disease
Blood in urine
Kidney Stones
Kidney Transplant
None of these
47
Have you been told you have/had: Pericarditis (Heart), Pleurisy (Lungs)?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
48
Have you been diagnosed with any of the following?* This field is required.Please select all that apply. Copyright © 2022. RheumOne, PLLC. All rights reserved
Heart "Pericarditis/Pericardal Effusion" *Not CAC/MI/Valve Disease/Arrythmia*
Lungs "Pleuricy" *Not Pneumonia/COPD/Bronchitis*
Lung Scoring/Pulmonary Fibrosis
Stomach "Gastritis" *Not Stomach Ulcers*
None
49
Rash and/or skin changes?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
50
Do you have any skin changes that are listed below?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Ulcer
Flat
Raised
Scales
Scabs
Scarring
Outside Surface Joint
Inside Surface Joint
Between Joints
51
Hair loss?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
52
What type of hair loss are you experiencing?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Thinning
Bald areas/ Alopecia
Total loss
53
Hair Loss Type* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Male Pattern Baldness
Patchy
54
Blood clots in lungs or legs (PE-Pulmonary Embolism) (DVT-Deep Vain Thrombosis)?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
55
Low or High WBC, Low RBC (Anemia)?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
56
Seizures?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
57
Hands/Feet change color when cold (Red, Blue or white) (Raynaud's)?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
58
Skin tightening around fingers and face?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
YESNO
59
Do you have any of the following symptoms/diagnosis?* This field is required.Copyright © 2022. RheumOne, PLLC. All rights reserved
Dental Disease
Can NOT swallow food without liquid
Watery eyes
Can NOT make tears
None of these
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Please leave a comment with any additional information you feel is relevant.Copyright © 2022. RheumOne, PLLC. All rights reserved
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Please Note: Your results may take up to 30 mins for review. At that time you will recieve an email with results and further instructions.

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