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Please fill in and return electronically to IIR by clicking "Submit" at bottom

If you, after consultation with your health care provider, want to participate in the study of
IL-1a aAb in your blood, you must answer the questionnaire below.
To get information on your disease process, and before each of the subsequent four tests can be carried out, the same form must be updated and accompany each blood sample.

Mandatory information is marked with an asterisk *

Info feed-back
*Email Address:
 Optional Email Address:

If you provide both addresses, information will be forwarded to each of them.
Please keep us informed of changes in these addresses.
Our only contact with you is by email.

Patient information
*Intitials of Patient (ex.WJC): *Sex :

*Race:
*Birthday YYYY/MM (ex.1958/04):
*Country:

Diagnosis
*Diagnosis:

*Date of Diagn. YYYY/MM:

 Diagnostic criteria, see
1987 ACR class. for rheum. diseases

Clinical data
*Morning Stiffness:
 *Fatigue:
 *Number of joints with:
Swelling:Pain:

Other data
Eryhtrocyte SR (mm/h): Larsen wrist X-ray index:

Left:Right:
Rheumatoid factor (titer):

The above is important for evaluation of disease severity. Please give as much info as possible.
Use Comments below, if other activity parameters are at hand.

Blood sampling
*Sample: Allow sample storage at IIR:

Note: Please provide date of blood sampling with your shipment.

Therapy (orally and/or systemically)
*Have you received glucocorticoids in the last 3 months?
If Yes, please detail:

Cummulated dosage last 3 months (mgs):
*Other immunosuppressive drugs in the last 3 months?
If Yes, please detail:
Other relevant therapies:
If Yes, please detail:

Comments

IMPORTANT: For correct feed-back, please take a moment to ensure that
everything is filled in with the correct information, then click the Send formmail button...

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