Download BASELINE CRF Biomarkers of Systemic Treatment Outcomes in Psoriasis Single Sample Sites

Biomarkers of Systemic Treatment Outcomes in Psoriasis
BASELINE CRF
Single Sample Sites
B S T
B-STOP ID:
Version 8
BADBIR ID:
Initials:
D.O.B:
d
d
m
m
y
Gender:
y
Male
Female
ETHNICITY (Please circle): White / Black or Black British / Asian or Asian British / Chinese / Mixed background / Other
If Mixed Background / Other, please specify:
1. PATIENT CONSENT
1a. Is the patient due to enrol onto BADBIR or already on BADBIR? YES
NO
(Not eligible for recruitment)
1b. Has the patient given written Informed Consent for B-STOP?
NO
(Not eligible for recruitment)
1c. Date of Consent to B-STOP :
d
d
m m
y
YES
y
1d. Does this patient consent to Psoriasis Biobank? (see Q.8 on Consent Form)
YES
NO
1e. Does this patient consent to being recalled? (see Q.9 on Consent Form)
YES
NO
2. TREATMENT DETAILS
Please tick the boxes and complete details for all the patient’s current or expected Psoriasis treatments:
Biologic drugs
Drug name
Dose (mg) Frequency
Date started
Adalimumab
d
d
m m
y
y
Ustekinumab
d
d
m m
y
y
Other - write name
d
d
m m
y
y
Conventional drugs
Drug name
Dose (mg) Frequency
Date started
Methotrexate
d
d
m
m
y
y
Other - write name
d
d
m
m
y
y
If the patient is taking Methotrexate, is this being taken subcutaneously (by injection) ? YES
NO
3. CURRENT STATUS - Please indicate the current disease severity
3a. PASI
3b. DLQI
Date of assessment:
d
d
m
m
y
y
3c. Psoriasis Global Assessment
Severe
Moderate to Severe
Moderate
Mild
Clear
Almost Clear
4. SAMPLE COLLECTION
Please tick boxes to confirm collection
4a FOR ALL PATIENTS - DNA SAMPLE
2 x 6ml PINK TOP tube
1
2
Freeze within 4 hours
Clinician’s Name:_________________________________________
Clinician’s Signature:______________________________________
Version 8, 14/01/2015
Date: d
d
m m
y
y