Sunnyside Clinic
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Gestaltometer 2
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Gestaltometer 2
[Title]
Patient Name:
Date of Birth:
Date:
Swollen Joints:
Count (All):
Count (28 Joints):
Tender Joints
Count:
Count (28 Joints):
Damaged /
Replaced
Count:
Notes from Consult:
How would you score your pain in the last 7 days out of 10?
Are you satisfied with current pain control?
Yes
No
How many days of work have you lost in the last 3 months?
How many good days have you had in the last 7?
Patient Global Score (/10)
Physican Global Score (/10)
ESR
CRP (mg/dl)
SDAI:
CDAI:
DAS28:
HAQ:
Function since last visit
Better
+2
Same
0
Worse
-2
Disease Control
Better
+2
Same
0
Worse
-3
Early morning stiffness
0-30 mins (+1)
+1
30-120 mins (-1)
-1
>120 mins (-2)
-2
I want to change my treatment
No (+1)
+1
Unsure (0)
0
Yes (-2)
-2
Drug toxicity
None (+2)
+2
Mild (-1)
-1
Severe (-5)
-5
On Prednisone
No (+1)
+1
<10mg (-2)
-2
>10mg (-3)
-3
Swollen joint count
0 (+2)
+2
1-5 (-2)
-2
>5 (-3)
-3
Physician global score
Remission (+2)
+2
Mild-Mod (-1)
-1
Severe (-3)
-3
Radiological change
None (+2)
+2
Stable (-1)
-1
New (-3)
-3
CRP value
Normal (+2)
+2
Up to 2x
ULN
(-1)
-1
Over 2x
ULN
(-3)
-3
Joint deformities
None (+2)
+2
Stable (-1)
-1
New (-2)
-2
Rh F, CCP or nodules
No (+1)
+2
Yes (-2)
-2
Completed By:
Comments (Medication, changes, pregnancy, blood monitoring):
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