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Gout Symptoms Check-In and Family History

Version: 1.0
URL: http://quickq.io/instruments/gout-checkin

Synthetic gout check-in form. Covers question types: date, datetime, multiple_choice, grid, slider, ranked, boolean, numeric, text.

Recent Attacks

1. When did your most recent gout attack begin? gout.last_attack_date · date

Date

2. Date and time your most recent gout attack began (if known): gout.last_attack_datetime · datetime

Date and time

3. How many gout attacks have you had in the past 12 months? gout.attacks_12mo · numeric

Numeric response

4. Which joints were affected in your most recent attack? (select all that apply) gout.attack_joints · multiple_choice

  • big_toe Big toe (either foot)
  • ankle Ankle
  • knee Knee
  • wrist Wrist
  • elbow Elbow
  • finger Finger joints

Current Symptoms

5. Rate pain and swelling in each joint right now: gout.joint_severity · grid

None (0) Mild (1) Moderate (2) Severe (3)
Right big toe
Left big toe
Right ankle
Left ankle
Right knee
Left knee

Family History

6. Which blood relatives have been diagnosed with gout? (select all that apply) gout.family_gout · multiple_choice

  • father Biological father
  • mother Biological mother
  • sibling Brother or sister
  • mat_gp Maternal grandparent
  • pat_gp Paternal grandparent
  • cousin First cousin, aunt, or uncle
  • none None of the above

Management & Labs

7. Are you currently taking a urate-lowering therapy (e.g., allopurinol, febuxostat, probenecid)? gout.on_ult · boolean

  • Yes / No

8. Most recent serum uric acid level (mg/dL): gout.uric_acid · numeric

Numeric response

9. Date of that uric acid blood test: gout.uric_acid_date · date

Date

10. How would you rate your overall gout-related pain right now? (0 = no pain, 100 = worst imaginable pain) gout.pain_vas · slider

Slider (visual analog scale)

Self-Management

11. How confident are you in each of these self-management approaches? gout.management_confidence · grid

Not confident (1) Slightly confident (2) Moderately confident (3) Very confident (4)
Following a low-purine diet
Taking medication as prescribed
Staying hydrated
Reducing alcohol intake
Recognizing flare warning signs

Priorities & Notes

12. Rank the following treatment goals from most important (1) to least important (5) to you: gout.treatment_priorities · ranked

  • pain_relief Reducing pain during attacks
  • prevention Preventing future attacks
  • side_effects Minimizing medication side effects
  • function Maintaining daily activities
  • uric_acid Reaching target uric acid level

13. Any additional information you would like your care team to know: gout.notes · text

Free-text response