Rheumatoid Arthritis / Inflammatory Arthritis Annual Review Form

If you have been advised by the surgery to submit a Rhaumatoid or Inflammatory Arthritis review please use this form.

Last Updated: 02/03/2023

Your Details

Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Phone Number (optional)

Email Address
Annual Review

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

Weight

Smoking Status

Smoker

Ex-Smoker

Non-Smoker

Blood Pressure (optional)

Systolic "Higher" / Diastolic "Lower" and Heart Rate (if able to record at home)

How many units of alcohol do you consume per day ? (1 unit of alcohol = half a pint of beer or 1 small glass of wine or 1 single measure of spirits or 1 single measure of aperitifs or 1 small glass of sherry. Anything above these measurements is more than 1 unit)

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? (optional)

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 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 and 10 = Extremely Painful (optional)

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?

Yes

No

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

Do you feel you need more support 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?

Yes

No

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

Is there any history of osteoporosis in your family?

Yes

No

Over the last 2 weeks, how often have you been bothered by the following problem? Little interest of pleasure in doings:

Not at all

On Several days

More than half the days

Nearly everyday

Over the last 2 weeks, how often have you been bothered by the following problem? Feeling down, depressed or hopeless:

Not at all

On Several days

More than half the days

Nearly everyday

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. (optional)

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

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Rheumatoid Arthritis / Inflammatory Arthritis Annual Review Form

Your Details

Annual Review