Gestaltometer Test

[Title]
Patient Name: Date of Birth: Date:
Count (All):



Count (28 Joints):
Tender Joints
Count:


Count (28 Joints):
Notes from Consult:
How would you score your pain in the last 7 days out of 10?
Are you satisfied with current pain control?
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
Same0
Worse-2
Disease Control
Better+2
Same0
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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