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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