BSR Biologics Register Clinical Baseline Form Please complete the following PATIENT information Clinical baseline form version 9:10/08/20111. Does the patient have rheumatoid arthritis?
If NO, can you specify the other diagnosis? 2.a) What was the year of diagnosis? 2.b) What year was this patient first seen by a rheumatologist? 3. ACR Criteria (please indicate which of the following apply to the patient)
Arthritis or deformity/damage of three or more joint areas (PIP, MCP, wrist, elbow, knee, ankle, MTP) (now)
Rheumatoid factor positive (≥ 1/40) (ever)
4. Systemic features: Has the patient ever had any of the following?
Serosal involvement (pleurisy/pericarditis)
Clinical baseline form version 9:10/08/20115. Joint replacements/surgery: Has the patient ever had any of the following? Unilateral Bilateral
6. Please indicate the current disease activity (i.e. at the time the patient started the new 7. Drug therapy: Please list all the patient’s current treatment, for any indication Clinical baseline form version 9:10/08/20118. New Biologic therapy: Etanercept Adalimumab Which biologic Certolizumab has the patient Infliximab Rituximab started? Anakinra Tocilizumab Please specify
Please indicate the date of first biologic therapy dose:
Please also indicate the average dose and unit:
Is this the patient’s first exposure to a biologic agent?
If NO, please give details below Concommitant DMARD DAS28 prior to Reason for Biologic therapy Start date Stop date starting stopping
Is the patient still on biologic therapy?
If NO, please give details on a separate sheet 9. Is the patient currently receiving DMARD therapy? Yes
If yes, please indicate which DMARD(s) and current dose
DMARD Started Frequency Date Started Methotrexate Azathioprine Cyclophosphamide Cyclosporine Leflunomide Other________________ Other _______________ Clinical baseline form version 9:10/08/201110. Previous second-line drug therapy: Has the patient EVER had any of the following drugs? No Don’t know We would now like to know more details about certain drugs: 1st Course 2nd Course Date started: Date stopped: Date started: Date stopped: No Don’t know If patient has started or stopped the same drug more than twice please give details on an additional sheet (Do not include stopping a drug for less than three months) Clinical baseline form version 9:10/08/201111. Co-morbidity: Has the patient ever had (i.e. required treatment for) any of the following illnesses? Please tick all that apply
YesNoknow Year of onset
Cancer‡ ‡If the patient has (or has ever had) cancer please specify date of diagnosis and site(s): Clinical baseline form version 9:10/08/201112. Smoking status: Is the patient a: 13. Blood pressure: what is the patient’s current (i.e. at the time that the biologic agent was started) blood pressure? 14. Height and weight: what is the patient’s current (i.e. at the time that the biologic agent was started) height and weight? 15. Did the patient have a chest x-ray prior to starting the new therapy? This form should be accompanied by the following pre-biologic therapy patient- completed forms: Thank you for completing this form! Clinical baseline form version 9:10/08/2011
Note To Attending Physician/Prescriber Personal Consult Physician: Physician, Unassigned This review is based on the information provided. Background Patient with dementia and behaviors and now non-responsive, will not talk, does not interact per family. Recent psych admission d/t behaviors likely related to her dementia. On Exelon Patch, Ativan prn, Seroquel prn, Trazadone, Namenda