Patient
Unique identification code
text
Hospital Unique Patient number or code
text
Initials
text
Patient Firstname
text
Patient Surname
text
Date of birth
date
Gender
text
AB0 Group
text
Rhesus Factor
text
Disease
Date of diagnosis
date
Primary Disease Diagnosis
text
Primary Disease Diagnosis
text
INITIAL DIAGNOSIS
SUBCLASSIFICATION AT DIAGNOSIS
integer
DISEASE STATUS
integer
LABORATORY DATA
integer
AUTOANTIBODIES
boolean
Specify antibody
integer
FIRST LINE THERAPIES
DISEASE MODIFYING DRUGS AND IMMUNOSUPPRESSANTS
boolean
Yes, mark appropriate box(es)
integer
COMPLICATIONS DUE TO TOXICITY FROM CONVENTIONAL TREATMENT
boolean
if yes, splease specify:
integer
DATE OF HSCT
STATUS OF DISEASE AT MOBILISATION
Eular/ACR 28 joint count, which comprises bilateral shoulders, elbows, wrists, MCPs, PIPs and knees. Appendix B.2)
integer
Eular/ACR 28 joint count, see above
integer
(Appendix B.3)
text
Was morning stiffness present?
integer
Patient's weight
integer
Patient's height
integer
Patient's weight one year prior to time of mobilisation
integer
Patient's height one year prior to time of mobilisation
integer
HAEMATOLOGICAL VALUES
Haemoglobin
text
Erythrocyte sedimentation rate
integer
Platelets
integer
WBC
integer
CLINICAL AND LABORATORY DATA
Serum creatinine
integer
Serum AST
integer
Serum ALT
integer
Serum albumin
integer
Serum alkaline phosphatase
integer
Total serum bilirubin
integer
C-reactive protein
integer
AUTOANTIBODIES
RADIOGRAPHIC EVALUATION
Were radiographic bone erosions present?
integer
Was advanced skeletal age of affected joints noted radiographically?
integer
Presence of osteoporotic fractures
integer
HEALTH ASSESSMENT
HEALTH ASSESSMENT QUESTIONNAIRE OR SURVEY COMPLETED
boolean
PATIENT’S SELF ASSESSMENT
integer
Childhood Health Assessment Questionnaire (CHAQ) completed?
integer
Specify range of possible scores for the CHAQ pain sub-scale
integer
Specify range of possible scores for the CHAQ disability sub-scale
integer
Specify range of possible scores for the CHAQ severity sub-scale
integer
PHYSICIAN’S ASSESSMENT
Did the physician complete a Global Assessment of the patient’s state?
boolean
If yes: Specify range of possible scores for Physician Rated Global Assessment
integer
DISEASE RESPONSE TO THE MOBILISATION TUMRSA2
integer
STATUS OF DISEASE AT HSCT
Eular/ACR 28 joint count, which comprises bilateral shoulders, elbows, wrists, MCPs, PIPs and knees. Appendix B.2)
integer
Eular/ACR 28 joint count, see above
integer
(Appendix B.3)
text
Was morning stiffness present?
integer
Patient's weight
integer
Patient's height
integer
Patient's weight one year prior to time of mobilisation
integer
Patient's height one year prior to time of mobilisation
integer
Haemoglobin
text
Erythrocyte sedimentation rate
integer
Platelets
integer
WBC
integer
Serum creatinine
integer
Serum AST
integer
Serum ALT
integer
Serum albumin
integer
Serum alkaline phosphatase
integer
Total serum bilirubin
integer
C-reactive protein
integer
Were tests for autoantibodies done between diagnosis and mobilisation/transplant?
boolean
Specify antibody
integer
Were radiographic bone erosions present?
integer
Was advanced skeletal age of affected joints noted radiographically?
integer
Presence of osteoporotic fractures
integer
HEALTH ASSESSMENT QUESTIONNAIRE OR SURVEY COMPLETED
boolean
PATIENT’S SELF ASSESSMENT
integer
Childhood Health Assessment Questionnaire (CHAQ) completed?
integer
Specify range of possible scores for the CHAQ pain sub-scale
integer
Specify range of possible scores for the CHAQ disability sub-scale
integer
Specify range of possible scores for the CHAQ severity sub-scale
integer
Yes, mark appropriate box(es)
integer
COMPLICATIONS DUE TO TOXICITY FROM CONVENTIONAL TREATMENT
boolean
if yes, splease specify:
integer
STATUS AT 100 DAYS POST-HSCT
Eular/ACR 28 joint count, which comprises bilateral shoulders, elbows, wrists, MCPs, PIPs and knees. Appendix B.2)
integer
Eular/ACR 28 joint count, see above
integer
(Appendix B.3)
text
Was morning stiffness present?
integer
Patient's weight
integer
Patient's height
integer
Patient's weight one year prior to time of mobilisation
integer
Patient's height one year prior to time of mobilisation
integer
Haemoglobin
text
Erythrocyte sedimentation rate
integer
Platelets
integer
WBC
integer
Serum creatinine
integer
Serum AST
integer
Serum ALT
integer
Serum albumin
integer
Serum alkaline phosphatase
integer
Total serum bilirubin
integer
C-reactive protein
integer
Were tests for autoantibodies done between diagnosis and mobilisation/transplant?
boolean
Specify antibody
integer
Were radiographic bone erosions present?
integer
Was advanced skeletal age of affected joints noted radiographically?
integer
Presence of osteoporotic fractures
integer
HEALTH ASSESSMENT QUESTIONNAIRE OR SURVEY COMPLETED
boolean
PATIENT’S SELF ASSESSMENT
integer
Childhood Health Assessment Questionnaire (CHAQ) completed?
integer
Specify range of possible scores for the CHAQ pain sub-scale
integer
Specify range of possible scores for the CHAQ disability sub-scale
integer
Specify range of possible scores for the CHAQ severity sub-scale
integer
Yes, mark appropriate box(es)
integer
COMPLICATIONS DUE TO TOXICITY FROM CONVENTIONAL TREATMENT
boolean
if yes, splease specify:
integer
FORMS TO BE FILLED IN