Rheumatoid arthritis / inflammatory arthritis annual review

Section

Weight:

Blood Pressure

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Smoking status:

Smoker

Non smoker

Ex smoker

How many cigarettes do you smoke per day?

Alcohol Intake

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 many units of alcohol do you consume per day?

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: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Walk outdoors on flat ground: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Get on/off toilet: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Reach and get down an object (such as a bag of sugar) from just above your head: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Open car doors: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Do outside work (such as gardening): *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Wait in a line for 15 minutes: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Lift heavy objects: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Move heavy objects: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

Go up two or more flights of stairs: *

Without Any Difficulty

With Some Difficulty

With Much Difficulty

Unable to do

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

0 = pain free
10 = extremely painful

How much pain, on a scale from 0-10, have you had because of your illness in the past week?

Considering all the ways that your illness affects you, rate how you are doing on a scale of 0-10:

Can you tell us how well managed your arthritis is at the moment?

Are you happy with your treatment?

Have you had recent changes in your treatment or flares of your disease?

Do you feel you need more support or aids at home and if so, can you describe why and what you think you might need?

Have you had any falls in the last year? If so, how many?

Do you feel that you are managing and tolerating your current medications?

Do you have any questions about your medications (please describe)?

Is there any history of osteoporosis in your family?

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

Little interest or pleasure in doing things:

Not at all

On Several days

More than half the days

Nearly every day

Feeling down, depressed or hopeless:

Not at all

On Several days

More than half the days

Nearly every day

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.

Please let us know if there is anything else regarding your arthritis or recommendations for us on improving our service:

Please let us know if you feel you need a face to face review:

*

I confirm that the information provided is accurate to the best of my knowledge

Tell us whether you accept cookies

Rheumatoid arthritis / inflammatory arthritis annual review

Section

Blood Pressure

Alcohol Intake

This is one unit of alcohol:

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