Doctor's name

 Patient name
Address Reference number
  Address
Phone number  
Fax number Phone number
email Medical aid Number
Request for 

 

Diagnosis

Previous therapy / Failed or intolerance to other DMARDs
 

DMARD

 Duration of therapy Reason stopped
Date of Diagnosis Methotrexate      
Duration of disease Antimalarial      
Rheumatoid arthritis   Sulphasalazine      
Ankylosing Spondylitis   Leflunomide      
Psoriatic Arthritis   Gold      
Juvenile idiopathic   Penicillamine      
Other   Azathioprine      

 

Criteria for RA

 Criteria for Ankylosing spondylitis Criteria for Juvenile arthritis Signs of active disease
Symmetry   Thoraco-lumbar pain   Persistence 6 weeks   ESR mm/hr
Stiffness > 1 hour   Limited in 3 planes   Exclusion of other disease   CRP units
Hand joint   Chest expansion < 3 cm   < /= 4 joints-pauciarticular   Number swollen joints
>3 joint groups   Sacroiliitis   >/= 5 joints - polyarticular   Number tender joints
Nodules       Systemic  

Functional impairment
Radiology           Class 1. No restriction
Rheumatoid factor           Class 2. Discomfort
            Class 3. Self care
            Class 4. Dependent