Use this 5-minute self-assessment tool to examine your physical and daily activity, health, and how you manage therapy. This will help you look at how hemophilia is affecting your daily life. When you are done you can create a document to share with your healthcare team.
Part 1:
Physical
Activity
Part 2:
Daily
Living
Part 3:
Health
Part 4:
Therapy
Physical Activity
Daily Living
Health
Therapy
What is your current activity level?
How much time do you spend being active?
Compared to one year ago, you feel that your activity is:
What are your desired activity goals? (Select all that apply)
On any given day, you accomplish:
Rate your quality of life at the moment:
How much does your hemophilia A limit you at school or work?
How much does your hemophilia A limit your social activities?
How much does your hemophilia A cause you anxiety in your daily life?
Was there anything that you wanted to do over the last few weeks or months, but were not able to because of your hemophilia?
What kind of bleeds have you had over the last 6 to 12 months? (Select all that apply)
Over the next year, you expect your health to:
What are your desired fitness goals? (Select all that apply)
Are you currently on prophylaxis† therapy?
† Prophylaxis is a course of treatment to prevent bleeds.
What dose and frequency is prescribed by your team?
What dose and frequency do you actually do/take?
How challenging is it for you to follow the prescribed regimen?
Do you keep regular infusion records?
Have you and your healthcare team completed pharmacokinetic (PK) testing to personalize your treatment (timed factor levels to figure out half‑life, trough levels, peak levels, etc.)?
Have the results been discussed with you by your healthcare team yet?
Have you ever used an app to track your PK profile?
How helpful is/was the app for tracking your PK profile?
Do you think there is an opportunity to improve the management of your hemophilia A?
Please complete this section.
All done!
Download a PDF of your assessment.
You may want to share the PDF with your healthcare team and work with them to determine areas that can be improved through personalized therapy.