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Part Ill. First Consultation
Country
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Centre ID
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Patient ID
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Date of Consult
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DD slash MM slash YYYY
BP (Please enter SYS/DIA in mmHg)
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Weight (Kg)
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Seen as:
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Inpatient
Outpatient
Approximate days since last flare
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Days until flare completely resolved
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Flare resolution was
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Spontaneous
Medicated
Patient diagnosis was assisted by
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None, clinical examination only
Crystal Analysis
Ultrasound
X-ray imaging
Currently in Gouty Arthritis Flare
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Yes
No
Flare Trigger for this attack
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Unknown
Food/Medication/Activity
Food
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None
Food (not specified)
Alcohol Beverages
Sweetened drinks
Beans
Beef - meat
Beef - internal organs
Canned goods
Pork - meat
Pork - internal organs
Seafood - fish
Seafood - shellfish
Other
Medication
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None
Allopurinol
Anti-tuberculosis
Aspirin
Cyclosporin
Febuxostat
Herbal / Alt.Medicine
Loop diuretics
Niacin
Thiazide
Other
Activity
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None
Accident/Trauma
Blood loss/transfusion
Dialysis
Diarrhea
Diet (excessive)
Exercise
Heart attack
Hospitalization
Infection (ex. UTI. CAP)
Stroke
Surgical procedure
Other
Please specify other food Trigger
*
Please specify other medication trigger
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Please specify other activity trigger
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Number of joints involved in the current gout flare
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1 or few small joints
1 or 2 large joints [ankle, knee, wrist. elbow, hip, shoulder]
Polya1ticular (4 or more joints with arthritis involving more than 1 region (forefoot (MTP. toes), midfoot (tarsal), ankle/hindfoot, knee, hip, fingers, wirst elbow, shoulder, other): or, attack involving 3 separtate large joints]
Duration of pain prior to consult
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Less than 12 hours
Between 12 - 36 hours
More than 36 hours
Maximal pain intensity (Scale from 1 to 10) during ENTIRE GOUT FLARE PERIOD
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Equal or less than 4
5 - 6
7 or more
Pain intensity (Scale from 1 to 10) during the ACTUAL CONSULTATION
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Equal or less than 4
5 - 6
7 or more
GOUT Medication taken PRIOR TO THIS CONSULT (check all that apply)
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None
Unrecalled
Colchicine
Allopurinol
Febuxostat
Herbal / Alt. Medicine
Celecoxib
Diclofenac
Etoricoxib
Ibuprofen
Mefenamic
Naproxen
Topical NSAID
Unrecalled NSAID
IA Betamethasone
IV Hydroxycortisone
Oral Prednisone
IA Methylprednisone
Oral Methylprednisone
IA steroid
IV steroid
Oral steroid
Paracetamol
Tramadol
Paracetamol + Tramadol
Other
Please specify other GOUT Medication taken PRIOR TO THIS CONSULT
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Other Medications Taken PRIOR TO THIS CONSULT (check all that apply)
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None
Anti-tuberculosis
Aspirin
Clopidogrel
Statins (Ator/Sim/Rosu/etc.)
Fenofibrate
Losartan
Diuretics
Other anti-hypertensives
Insulin
Other anti-Diabetes Mellitus
Other
Please specify Other Medications, not listed above, Taken PRIOR TO THIS CONSULT
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GOUT Medication Prescribed by
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Family Medicine
General Practitioner
Internal Medicine/Subspecialty
OB/Gyne
Rheumatologist
Surgeon/Orthopedic
Other Allied Health Practitioners (Therapist, Nurse, Caregiver, etc.)
Non-medical Practitioner (Faith Healer, self-medicated)
Unrecalled
Is the patient compliant to medication (Self-reported compliance)
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Yes
No
Recent laboratory exam (tests done within 1-month duration):
Date
DD slash MM slash YYYY
Crea (umol/L)
Date
DD slash MM slash YYYY
HBA1c
Date
DD slash MM slash YYYY
Uric Acid (mg/dL)
Date
DD slash MM slash YYYY
Triglycerides (mmol/L)
Date
DD slash MM slash YYYY
AST (IU/L)
Date
DD slash MM slash YYYY
Total Cholesterol (mmol/L)
Date
DD slash MM slash YYYY
ALT (IU/L)
Date
DD slash MM slash YYYY
HDL(mmol/L)
Date
DD slash MM slash YYYY
FBS (mmol/L)
Date
DD slash MM slash YYYY
LDL (mmol/L)
Patient was treated
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Inpatient
Out patient
Procedure done during this consult/referral
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None
Arthrocentesis
Intra-articular steroid injection
Debridement/Debulking/Excision
Treatment by attending Rheumatologist FOR GOUT
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None
Colchicine
Allopurinol
Febuxostat
Celecoxib
Diclofenac
Etoricoxib
Naproxen
IA Betamethasone
IV Hydroxycortisone
Oral Prednisone
IA Methylprednisone
Oral Methylprednisone
Paracetamol
Tramadol
Paracetamol + Tramadol
Losartan
Fenofibrate
Other
Please specify other treatment by attending Rheumatologist FOR GOUT
*
Did the patient receive gout education?
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Yes
No
