Review Charts

If yes, was a discussion with the patient about the risks of the chosen therapy documented?

Newly prescribed
by you

Discussion documented

Discussion NOT documented

Newly prescribed
by other physician

Discussion documented

Discussion NOT documented

Medical Abbreviations Glossary of Terms

Patient ID:

You must enter a Patient Identifier to enable access to this data (This is for your use only.)

Date of most recent office visit:

Month: Year:

Are you the sole usual source of care for this patient's rheumatoid arthritis? (Check "No" if shared with the patient's primary care provider.)
Yes No

Patient Demographics
Gender:	Male Female
Year of Birth:
Race: (Check ALL that apply)	African American/Black	American Indian/Alaskan Native
	Native Hawaiian/Pacific Islander	Asian, Specify:
	Caucasian/White	Other, Specify:
	No Race Specified
Ethnicity:	Hispanic/Latino	Not Hispanic/Latino

1. Does the patient have a confirmed diagnosis of rheumatoid arthritis?

Yes No

1a. When was the diagnosis established?

Month: Year: Not documented

1b. When did you assume care of this patient?

Month: Year:

2. What medications are currently prescribed?
**optional add by:
Select drug name and press ADD to check appropriate box below

DMARD
	Abatacept (Orencia®)
	Adalimumab (Humira®)
	Anakinra (Kineret®)
	Azathioprine (Imuran®)
	Cyclophosphamide (CTX, Cytoxan®)
	Cyclosporine (CyA, Neoral®)
	Etanercept (Enbrel®)
	Gold (Solganol®, Myochrysine®, Ridaura®)
	Hydroxychloroquine (Plaquenil®)
	Infliximab (Remicade®)
	Leflunomide (Arava®)
	Methotrexate (MTX, Rheumatrex®)
	Penicillamine (Cuprimine®, Depen®)
	Rituximab (Rituxan®)
	Sulfasalazine (SZ, Azulfidine®)
Proton Pump Inhibitor
	Esomeprazole (Nexium®)
	Lansoprazole (Prevacid®)
	Omeprazole (Prilosec®)
	Pantoprazole (Protonix®)
	Rabeprazole (Aciphex®)
Glucocorticoid
	Dexamthasone (Decadron®)
	Methylprednisolone (Medrol®, Depomedrol®)
	Prednisone (Deltasone®)
Diuretic
	Bumetanide (Bumex®)
	Chlorothiazide (Diuril®)
	Furosamide (Lasix®)
	Hydrocholothiazide (Dyazide®, Hydrodiuril®, Maxzide®, Moduretic®)
	Metolazone (Zaroxolyn®)
	Spironolactone (Aldactone®)
ACE Inhibitor
	Benazepril (Lotensin®)
	Captopril (Capoten®)
	Enalopril (Vasotec®)
	Fosinopril (Monopril®)
	Lisinopril (Prinivil®, Zestril®)
	Moexipril (Aceon®)
	Quinapril (Accupril®)
	Ramipril (Altace®)
	Trandolapril (Mavik®)
Other Gastroprotective Agents
	Misoprostol (Cytotec®)

Non-selective NSAID
	Diclofenac potassium (Cataflam®)
	Diclofenac sodium (Voltaren®, Voltaren XR®)
	Diclofenac sodium with misoprostol (Arthrotec®)
	Diflunisal (Dolobid®)
	Etodolac (Lodine®, Lodine XL®)
	Fenoprofen calcium (Nalfon®)
	Flurbiprofen (Ansaid®)
	Ibuprofen (Prescription: Motrin®, Non-prescription: Advil®, Motrin IB®, Nuprin®)
	Indomethacin (Indocin®, Indocin SR®)
	Ketoprofen (Prescription: Orudis®, Oruvail®, Non-prescription: Actron®, Orudis KT®)
	Meclofenamate sodium (Meclomen®)
	Mefenamic acid (Ponstel®)
	Meloxicam (Mobic®)
	Nabumetone (Relafen®)
	Naproxen (Naprosyn, Naprolan®)
	Naproxen sodium (Prescription: Anaprox®, Non-prescription: Aleve®)
	Oxaprozin (Daypro®)
	Piroxicam (Feldene®)
	Sulindac (Clinoril®)
	Tolmetin sodium (Tolectin®)
Salicylate
	Aspirin, acetylsalicylic acid (Non prescription: Anacin®, Ascriptin®, Bayer®, Bufferin®, Ecotrin®)
	Choline and magnesium salicylate (CMT®, Tricosal®, Trilisate®)
	Choline salicylate, liquid only-(Arthropan®)
	Magnesium salicylate (Prescription: Magan®, Mobidin®, Mobogesi®, Non Prescription: Arthritab®, Bayer Select®, Doan's Pills®)
	Salsalate (Amigesic, Anaflex® 750, Disalcid®, Marthritic®, Mono-Gesic®, Salflex®, Salsitab®)
	Sodium salicylate (Available as generic only)
COX-2 selective NSAID
	Celecoxib (Celebrex)
Narcotic Anangesic
	Codeine (Tylenol® #3, T3)
	Fentanyl (Duragesic®, E-TRANS® Fentanyl)
	Hydrocodone (Vicodin®)
	Hydromorphone (Dilaudid®)
	Levorphanol (Levodromoran®)
	Meperidine (Demerol®)
	Methadone (Dalophine®)
	Morphine sulfate (MSIR®, MS Contin®, Oromorph®, Roxanol®)
	Oxycodone (Oxycontin, Percocet®, Percodan®, Tylox®)
Other Analgesic (non-opioid)
	Propoxyphene (Darvocet®)
	Tramadol (Ultram®)

None of the Above

3. If a DMARD is not prescribed, what is the reason?

Contraindicated

Patient refused

Inactive disease

Not documented

Other reason:

4. In the past 12 months has any DMARD been newly prescribed?

5. In the past 12 months was a drug in the following class newly prescribed: NSAIDs (selective or non-selective), glucocorticoids or narcotics?
Yes No
If yes, was a discussion with the patient about the risks of the chosen therapy documented?

Drug Category	Newly prescribed by you	Discussion documented	Discussion NOT documented	Newly prescribed by other physician	Discussion documented	Discussion NOT documented
NSAID (selective or non-selective)
Glucocorticoid
Narcotics