Clinician baseline_version 9 10_08_2011x

BSR Biologics Register
Clinical Baseline Form
Please complete the following PATIENT information
Clinical baseline form version 9:10/08/2011 1. 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 9:10/08/2011 5. 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 9:10/08/2011 8. 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 9:10/08/2011 10. 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 9:10/08/2011 11. Co-morbidity:
Has the patient ever had (i.e. required treatment for) any of the following illnesses? Please tick all
that apply

Yes No know
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 9:10/08/2011 12. 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

Source: http://www.medicine.manchester.ac.uk/images/File/Clinician%20baseline_Version%209%2010_08_2011x.pdf