Rheumatoid / Inflammatory Arthritis Annual Review

If you have been advised by the surgery to do so, please submit this form.

Please note – if you submit this request after 4pm on a working day, it will be opened when we re-open on the next working day. The practice is closed over the weekend.

Rheumatoid / Inflammatory Arthritis Annual Review

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 alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
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? *

Smoking

Smoking status: *

Smoker

What do you mainly smoke?
How many cigarettes do you smoke in a day? *
How many cigars do you smoke in a day? *
Would you like to give up smoking? *

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

Ex Smoker

What did you mainly smoke?
How many cigarettes did you smoke in a day? *
How many cigars did you smoke in a day? *

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
/

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)
(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:

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.