GENETIC ANALYSIS OF PSORIASIS AND PSORIATIC ARTHRITIS Department of Dermatology, University of Michigan

Transcription

1 GENETIC ANALYSIS OF PSORIASIS AND PSORIATIC ARTHRITIS Department of Dermatology, University of Michigan SELF ASSESSMENT FORM FOR STUDY SUBJECTS AND CONTROLS Accession Number (will be filled in by lab) Date: Name of Subject: Biological Parents' names: Father Mother Gender: Male Female Ethnicity: Hispanic n-hispanic Race: Check all that apply American Indian Caucasian African American Pacific Islander Arabic Asian (subcategory ) Other Date of birth: Do you have a history of any of the following? 1. Diabetes mellitus Don t know 2. Hypertension (high blood pressure) Don t know 3. Myocardial infarction (heart attack) Don t know 4. Angina (chest pain) Don t know 5. High cholesterol or triglycerides Don t know

2 Have you been diagnosed with Crohn s disease or another inflammatory bowel disorder? Explanation: (diagnosis if known, date of diagnosis, doctor who made the diagnosis) Have you been diagnosed with any type of autoimmune disease (lupus, scleroderma, etc.)? Explanation: (diagnosis if known, date of diagnosis, doctor who made the diagnosis) Do you have any blood relatives affected with psoriasis? If yes, relationship(s): Do you have any blood relatives with inflammatory bowel disease? Explanation: (for each type of relative, please give presumed diagnosis) Do you have any blood relatives with any type of autoimmune disease? Explanation: (for each type of relative, please give presumed diagnosis) Alcohol and tobacco usage: How many of the following do you smoke per day? Cigarettes Cigars Pipes How many alcoholic drinks do you have per week (one drink = one beer = one glass of wine = one cocktail) Body measurements: About how much do you weigh? About how tall are you? pounds feet inches Waist size (at belly button) inches STOP HERE IF YOU ARE PARTICIPATING AS A CONTROL AND DO NOT HAVE PSORIASIS. Psoriasis self evaluation form page 2 of 7

3 If affected with psoriasis: Age at which symptoms appeared: Age at which psoriasis was diagnosed by a physician: Is the physician who diagnosed you a dermatologist: If affected with arthritis: Age at which symptoms appeared: Age at which arthritis was diagnosed by a physician: Have you been told by a rheumatologist that you have psoriatic arthritis? Life changing events prior to onset of psoriasis or psoriatic arthritis: 1 Death in the family? Don t know 2. Divorce? Don t know 3. Loss of job? Don t know 4. Any other stress factors? (please specify) Possible trigger of psoriasis or psoriatic arthritis: 1. Strep throat (streptococcal pharyngitis)? Don t know 2. Other bacterial or viral infections? Don t know If yes, circle site(s): Sinus / Lung / Gastrointestinal / Genito-urinary / Meningitis / Skin Other 3. Climate change? Don t know If yes, specify: 4. Medications? Don t know If yes, specify: Psoriasis self evaluation form page 3 of 7

4 Physicians that have treatment/diagnosis records for you: Primary care provider contact information: Dermatologist's contact information: Rheumatologist's contact information: Other specialist's contact information: How bad is your psoriasis today? Please answer each of the following three questions by placing an X mark anywhere on the line to show how red, thick, and scaly an average spot of your psoriasis is. A. What color is an average spot of your psoriasis? redness Slight pink Pink Red Dark red B. How thick is an average spot of your psoriasis? thickness Feels firm Raised Thick Very thick C. How scaly is an average spot of your psoriasis? scale Slight scale Scaly Flaky Very flaky D. Has a dermatologist told you that you have pustular psoriasis? E. Do you have nail psoriasis (pitting of nail surface, thickened or crumbly nails, excessive separation of the tips of the nails from the nail bed, or yellow-orange spotting of the nails)? If yes, number of fingernails affected ; number of toenails affected Psoriasis self evaluation form page 4 of 7

5 Below, please mark for each body area, how many palms of your hand do you think would cover all the patches of psoriasis TODAY and WHEN IT WAS THE WORST IT HAS EVER BEEN. If your psoriasis is scattered small dots, try to imagine combining them together into one patch Please remember to include your scalp and back if affected Do not include areas in which psoriasis has faded, leaving only changes in the color of skin 1 palm = circled area Today Worst ever Head, including neck and face: palms palms Right arm, shoulder to fingers: palms palms Left arm, shoulder to fingers: palms palms Trunk, front, back and sides: palms palms Right leg, hip to toes: palms palms Left leg, hip to toes: palms palms Psoriasis self evaluation form page 5 of 7

6 The Psoriatic Arthritis Clinic, Centre for Prognosis Studies in the Rheumatic Diseases University of Toronto, University Health Network, Toronto Western Hospital July 1999 GENETIC ANALYSIS OF PSORIASIS AND PSORIATIC ARTHRITIS Department PSORIATIC of ARTHRITIS Dermatology, SCREENING University QUESTIONNAIRE of Michigan PSORIATIC ARTHRITIS SCREENING QUESTIONNAIRE STUDY #: Date: / / year month day PLEASE TICK ( ) EACH CORRECT RESPONSE OR FILL IN THE BLANK FOR ALL QUESTIONS ON BOTH SIDES OF THE PAGE. You may have already answered some of the questions in this standardized Date of Birth: / / Gender: Male Ethnic Background: White questionnaire. Kindly answer them again for consistency. year month day Female East Indian Black Filipino Chinese Other (specify) Mixed (specify) Date: Patient s Name: Figure 1 Skin rash on the elbows Figure 2 Pits in the nail Figure 3 Lifting of the nail 1. Have you ever had a skin rash consisting of red AND silvery-white scaly areas particularly on the elbows, knees or scalp 1. Have you ever had a skin rash consisting of red and silvery-white scaly as areas shown particularly in FIGURE 1? on the elbows, knees or scalp as shown in FIGURE 1? IF YES At approximately what age did you first notice this skin rash? Psoriasis self evaluation form page 6 of 7 IF YES At Do approximately you have this skin rash what now? age did you first notice this skin rash? years old Do you have this skin rash now? 2. Have you ever noticed any of these changes in your fingernails: 2. Have Pits in you the nails ever as noticed shown in any FIGURE of the 2. following changes in your fingernails: Lifting of the nail from the nail bed as shown in FIGURE 3. Pits IF YES in the At nails approximately as shown what in age FIGURE did you first 2. notice them? Lifting of the Do you nail have from either the of nail these bed nail changes as shown now? in FIGURE 3. IF YES At approximately what age did you first notice them? 3. Have you ever seen a doctor about a skin rash? Do you have either of these nail changes now? Has Have a doctor you ever diagnosed seen a doctor you with about psoriasis? a skin rash? IF YES At approximately what age were you diagnosed? 4. Has a doctor ever diagnosed you with psoriasis? 5. Have you ever had joint pain, joint stiffness or swollen red joints that was not the result of injury? IF YES At approximately what age were you diagnosed? IF YES At approximately what age did you first notice these symptoms? 5. Have you ever Do you had have joint any pain, symptoms joint now? stiffness or swollen red joints that was not the result of injury? 6. Have you ever had a Zsausage shaped[ swollen finger or toe that was not the result of an injury? IF YES At approximately what age did you first notice these symptoms? PLEASE TURN OVER AND COMPLETE THE OTHER SIDE OF THE PAGE Page ½ Do you have any symptoms now? 6. Have you ever had a sausage shaped swollen finger or toe that was not the result of an injury?

7 7. Have you ever had neck pain lasting at least 3 months that was not injury related? IF YES Was the neck pain accompanied by stiffness? Do you have any neck pain now? 8. Have you ever had back pain lasting at least 3 months that was not injury related? IF YES Was the back pain accompanied by stiffness? Do you have any back pain now? 9. Have you ever had a skin rash on any part of your body at the same time as joint pain, joint-stiffness or swollen red joints? IF YES At what age did you first notice these symptoms? Psoriasis self evaluation form page 7 of 7 Do you have these symptoms now? 10. Have you ever seen a doctor about any joint pain? 11. Have you ever been diagnosed with any form of arthritis other than psoriatic arthritis? IF YES What kind of arthritis was it? (Check all that apply) Rheumatoid Arthritis Osteoarthritis Lupus (SLE) Fibromyalgia Ankylosing Spondylitis Scleroderma Other (specify) 12. Has a doctor ever diagnosed you with psoriatic arthritis? IF YES At what age were you first diagnosed? 13. For each family member below, indicate if they have PSORIASIS or not: Mother do not know not applicable Father do not know not applicable Brother(s) do not know not applicable Sister(s) do not know not applicable Grandparent(s) do not know not applicable Blood-related Uncle/Aunt do not know not applicable Son(s) do not know not applicable Daughter(s) do not know not applicable 14. For each family member below, indicate if they have PSORIATIC ARTHRITIS or not: Mother do not know not applicable Father do not know not applicable Brother(s) do not know not applicable Sister(s) do not know not applicable Grandparent(s) do not know not applicable Blood-related Uncle/Aunt do not know not applicable Son(s) do not know not applicable Daughter(s) do not know not applicable