Rheumatoid Arthritis Review

If you have been advised by the surgery to submit a review of your rheumatoid arthritis please use this form.

Rheumatology Questionnaire

Patient Information

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Sex: *
Smoking Status:

Do you have or have you had any of the following?

Type 1 or 2?
Wrist, spine, hip or shoulder fracture:
Please specify:
Do either of your parents have osteoporosis/hip fracture:
Please specify:
Asthma or COPD:
Please specify:
Heart attack, angina, stroke or TIA:
Please specify:
Rheumatoid Arthritis or SLE:
Please specify:
Endocrine problems e.g. thyrotoxicosis, hyperparathyroidism or Cushing’s disease
Malabsorption e.g. Crohn’s disease, ulcerative colitis, celiac disease, steatorrhea or blind loop syndrome:
History of falls:
Parkinson’s Disease:
Chronic liver disease:
Chronic kidney disease:
Do you live in a nursing or care home?

Are you taking any of the following?

Steroid tablets regularly:
Oestrogen only HRT: