Juvenile Idiopathic Arthritis Genetics Questionnaire

The JIA Genetics Group in the Rheumatology Division of the Cincinnati Children's Hospital Medical Center is committed to maintaining contact with JIA patients and their families. We encourage patients and/or family members to fill out a short one page questionnaire to help us maintain current clinical and demographic information in our databases. This form is a secure and confidential method for updating your information.

JIA Genetics Questionnaire

Fields marked with an asterisk (*) are required.

Contact Information:

First tell us your name and how we can reach you:

Person with Juvenile Idiopathic Arthritis (JIA)
* Name:
Person completing form
* Name:
* Relationship:
Address of Person with JIA
* Address:
* City:
* State/Territory:
* Zip:
Country:
Email:
Phone Number:

Clinical Information Update

a) * Is your (or your child’s) primary diagnosis still JIA?	Yes No I don't know
a) * Is your (or your child’s) primary diagnosis still JIA?	If "No", please list current diagnosis:
b) * Has eye disease (uveitis) been diagnosed?	Yes No I don't know

c) * Are erosions present (abnormal x-rays or joint replacement surgery)?	Yes No I don't know
d) * Current Physician/Rheumatologist:	I don't know
d) * Current Physician/Rheumatologist:	Phone Number: I don't know

Please review the following list and check the medications which you (or your child) are now using or have used in the past.

Medications	Now	In the past
Prednisone/Prednisolone
Methotrexate, oral
Methotrexate, SQ
Etanercept
Infliximab
Adalimumab
Anakinra
Orencia
Rituximab
Abatacept

Newsletter feedback

a) Did you find the newsletter to be informative?	Yes No
b) What is your preferred method to receive future editions of the newsletter?	Email US Mail
c) Is there any information that you would like to see in future newsletters?

Additional Comments

JIA Genetics Group

Sandy Kramer, CRC
Recruiter and Study Manager
513-636-7692
513-636-4116 (fax)
JIAGenetics@cchmc.org

Divisions

Rheumatology

Awards & Recognition

As a not-for-profit hospital and research center, Cincinnati Children's Hospital Medical Center is dedicated to bringing the world the joy of healthier kids.

3333 Burnet Avenue, Cincinnati, Ohio 45229-3039

513-636-4200 | 1-800-344-2462 | TTY: 513-636-4900

Policies

Juvenile Idiopathic Arthritis Genetics Questionnaire