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Part I. Patient Characteristics/Gout History
Country
*
India
Indonesia
Iraq
Kazakhstan
Korea
Malaysia
Nepal
Philippines
Singapore
Taiwan
Thailand
Centre
*
ID-001
ID-002
IN-001
IQ-001
KR-001
KZ-001
MY-001
NP-001
PH-001
PH-002
PH-003
SG-001
SG-002
SG-003
SG-999
TH-001
TH-002
TH-003
TW-001
Patient ID
*
Province
Age
*
Gender
*
Male
Female
Height (m)
*
Please enter a number from
0
to
5
.
Weight (kg)
*
This field is hidden when viewing the form
Birthday
*
DD slash MM slash YYYY
Medical History
*
None
Blood Dyscrasia
Cancer
Chronic Kidney Disease
Coronary Heart Disease
Covid-19
Diabetes Mellltus
Dyslipidemia
Hypertension
Hypothyroidism
Menopause
Metabolic Syndrome
Nephrolithiasis
Psoriasis
Psoriatic Arthritis
Rheumatoid Arthritis
Septic Arthritis Stroke
SLE Tuberculosis
Others:
AgeDx (Chronic Kidney Disease)
*
AgeDx (Coronary Heart Disease)
*
AgeDx (Septic Arthritis Stroke)
*
Please specify other medical history
*
Family History
*
None
Unknown
Blood Dyscrasia
Cancer
Chronic Kidney Disease
Coronary Heart Disease
Covid-19
Diabetes Mellitus
Dyslipidemia
Gout
Hypertension
Hypothyroidism
Metabolic Syndrome
Nephrolithiasls
Psoriasis
Psoriatic Arthritis
Rheumatoid Arthritis
Stroke
SLE
Others
Please specify other family history
*
Personal Social History
Smoking Habit
*
Non-Smoker
Previous Smoker (Stopped for 1 year or more)
Current Smoker
Approximate pack years
*
Drinking Habit
*
Non-alcohol beverage drinker
Alcohol beverage drinker
Alcohol beverage (most often intake)
*
Beer
Wine
Spirits
Alcohol Frequency of Intake
*
Less than once month
Once a month to once a week
Two to four times a week
Five times a week to once a day
Two or more a day
Alcohol Consumption
*
1 - 2 bottles/glasses/shots
3 - 4 bottles/glasses/shots
> 4 bottles/glasses/shots
Age at first Symptom
*
Age at first consult
*
Age at diagnosis
*
Initial joint involvement
*
(Ask patient to point. Check all Involved)
Shoulder
Elbow
Wrist
MCP
DIP/PIP
Hip
Knee
Ankle
Midfoot
First MTP
Toes
Cervical Spine
Thoracic Spine
Lumbar Spine
Sacral Spine
Diagnosed by
*
Family Medicine
General Practitioner
Internal Medicine / subspecialty
OB/Gyne
Rheumatologist
Surgeon/Orthopedic
Other Allied Health Practitioners (Therapist. Nurse. Caregiver, etc.)
Non-medical Practitioner (ex. Faith Healer)
Unrecalled
Flare Triggers
Unknown
Known Food/Medication/Activity
Food
*
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
*
None
Allopurinol
Anti-tuberculosis
Aspirin
Cyclosporin
Febuxostat
Herbal/Alt. Medicine
Loop diuretics
Niacin
Thiazide
Other
Activity
*
None
Accident/Trauma
Blood loss/transfusion
Dialysis
Diarrhea
Diet (excessive)
Exercise
Heart attack
Hospitalization
Infection (ex. UT!. CAP)
Stroke
Surgical procedure
Other
Please specify other food trigger:
*
Please specify other medicine trigger:
*
Please specify other activity trigger:
*
Previous procedures done PRIOR TO INCLUSION in the study (check all that apply)
*
None
Arthrocentesis
Intra-articular steroid injection
Debridement/Debulking/Excision
GOUT Medication PRIOR TO INCLUSION in study (check all that apply)
*
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 PRIOR TO INCLUSION in study
*
Other Medications Taken
*
None
Anti-tuberculosis
Aspirin
Clopidogrel
Statins (Atoc/Sim/ Rosy)
Fenofibrate
Losartan
Diuretics
Other anti-hypertensives
Insulin
Other anti-Diabetes Mellitus
Other
Please specify other medication taken
*
Gout Medication Prescription BEFORE INCLUSION IN THE STUDY given by (check all that apply)
*
Family Medicine
General Practitioner
Internal Medicine/Subspecs
OB/Gyne
Rheumatologist
Surgeon/Orthopedic
Other Allied Health Practitioners (Therapist, Nurse, Caregiver. etc.)
Non-medical Practitioner (Faith Healer, self-medicated)
Unrecalled
