Rheumatoid Arthritis / Inflammatory Arthritis Annual Review Form

If you have been advised by the practice to complete a Rheumatoid Arthritis / Inflammatory Arthritis Annual Review please use this form.

Rheumatoid Arthritis / Inflammatory Arthritis Annual Review

Rheumatoid Arthritis / Inflammatory Arthritis Annual Review

Blood Pressure

If able to record at home.
/
Smoking status:

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 alcoholAmount of different types of drink representing more than one unit of alcohol

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

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

0 = pain free
10 = extremely painful

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:

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.