General Information  Hospital ID:  Entry date:  D   D   /   M   M   /   Y   Y   Name of center:   Patient name:   Location of app:      1. Patient Demographics   Date of BIrth:  D   D   /   M   M   /   Y   Y  In patient  Out patient  Male  Female  Patientweight:   kg Onset Date:  D   D   /   M   M   /   Y   Y  Abrupt onset  Gradual onset  Others    2. Stage     3. Haematology   At Diagnosis: High Disease Activity  C   D  Moderate Disease Activity  C   D    Low Disease Activity  C   D  Remission  C   D  Pediatric patients: None(for Adults) Polyarticular Oligoarticular Systemic CRP:  .  mg/I ESR: RF: +ve  -ve ANA: +ve  -ve Anti CCP: +ve  -ve  4. Latest  Severity Scores   5. Radiographic Scores   Tender joint Count: Swollen Joint count:  Vas: M.HAQ rating:  .  C.HAQ rating:  .  DAS 28  .  Bone Erosim: JSN: TSC:   6. Coexisting conditions Does the patient have any co-existing condition/s? COPD: Heart Disease: CHF: Diabetes: Osteoarthritis: TB: Others specify:    7. Current Treatment for RA   Brand Name of Drug(s) Currently Prescribed for RA Generic Name 1     Brand Name1 Dose per Application in mgs Frequency of Adminis-tration Reason of Switch/Withdrawal/Adding Date Initiated Month Year Drug 1        M   M   Y   Y  Drug 2        M   M   Y   Y  Drug 3        M   M   Y   Y  Drug 4        M   M   Y   Y  Drug 5        M   M   Y   Y   8. Previous Treatment for RA   Last three lines of treatment (Generic Name   Brand Name) Date Started Date Ended Reason for Switch / Withdrawal Most Recent  M   M     Y   Y   M   M     Y   Y    2nd Most Recent  M   M     Y   Y   M   M     Y   Y    3rd Most Recent  M   M     Y   Y   M   M     Y   Y     9. Safety Profile    10. Other Clinical Comments Adverse Events   Severity Mild Moderate Severe Major   Product related Yes  No Other Clinical Comments :