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Rheumatoid / inflammatory arthritis annual review

Rheumatoid / Inflammatory Arthritis Annual Review
Required fields are labelled
Who are you completing this form for?
For example, on behalf of a child or dependent
What is your name?
What is your date of birth?
For example, 31 3 1980
What is your sex?
As recorded on your medical record
The one used to register with your GP
Anyone else with access to your email account may see responses sent to you

About You

eg. 1.75
eg. 60.6

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? Required
How many units of alcohol do you drink on a typical day when you are drinking? Required
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Required

Smoking

Smoking status: Required

Blood Pressure

Please provide a blood pressure reading if you have access to a machine.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Please use date format: DD/MM/YYYY

Daily activities

We are interested in learning how your illness affects your ability to function in daily life. In the last week, how would you rate your ability to do each of the following tasks?

Stand up from a straight chair: Required
Walk outdoors on flat ground: Required
Get on/off toilet: Required
Reach and get down an object (such as a bag of sugar) from just above your head: Required
Open car doors: Required
Do outside work (such as gardening): Required
Wait in a line for 15 minutes: Required
Lift heavy objects: Required
Move heavy objects: Required
Go up two or more flights of stairs: Required

Pain and your illness

We are also interested in learning whether or not you are affected by pain because of your illness.

(0 = pain free, 10 = extremely painful)
(0 = pain free, 10 = extremely painful)

Further questions

Further questions

Over the last 2 weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things:
Feeling down, depressed or hopeless:

Before you submit your review

Please ensure you are happy with the required monitoring checks for your medication:

  • Sulfasalazine – every 2 weeks until on stable dose for 6 weeks. Once on stable dose, monthly blood tests for 3 months. Thereafter, at least every 12 weeks for 12 months, then no routine monitoring needed.
  • Methotrexate – every 2 weeks until on stable dose for 6 weeks. Once on stable dose, monthly blood tests for 3 months. Thereafter, at least every 12 weeks.
  • Penicillamine – blood test and urinalysis every 2 weeks until dose stable for 3 months and then monthly.
  • Leflunomide – every 2 weeks until on stable dose for 6 weeks. Once on stable dose, monthly blood tests for 3 months. Thereafter, at least every 12 weeks.