Online Risk Assessment First Name Last Name Email Phone Date of Birth -- Month -- -- Day -- -- Year -- Do you have arthritis? Yes No I do not know if I have arthritis Do you have joint pain? Yes No If you experience joint pain is it impacting the quality of your life? Yes No How has joint pain changed over the past 12 months? Improved Worse No change My pain limits my ability to complete normal everyday tasks such as getting ready for the day, showering, dressing, cooking, cleaning, participating in family activities or gardening to name a few. Yes Very much No A little I enjoy exercise and I can participate in all the fitness activities just as I did five years ago. Yes No Some but with limitations I take over the counter medicine to help control my pain. Yes Daily Weekly No Occasionally My joint pain is causing me to feel stress Yes All the time Sometimes No I have tried the following items to stop joint pain. I have tried everything that I can think of to stop joint pain. I take over the counter medicine and self-manage my pain. I have attended physical therapy and I am doing physical therapy exercises. I have not made an appointment to see a doctor. I am under the care of a physician. My physician has referred me to pain management medicine. Yes No My physician has recommended Ortho surgery for my pain. Yes No By checking this box, I agree to receive communications from Florida Hospital and Adventist Health System.