GOUT DATABASE
GOUT Patients from 2013 onwards
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General Data
Demographics
Name *
Last, First, MI
Case Number *
Contact Number *
Mobile / Landline
Gender *
Height *
feet/inch
Weight *
in kilograms
Education *
Civil Status *
Alcohol Intake *
Smoking *
Herbals *
Past Medical History *
Required
Medication History *
Required
GOUT DIAGNOSIS
Date of Onset of Symptoms *
MM
/
DD
/
YYYY
Date of Gout Diagnosis *
MM
/
DD
/
YYYY
Age at Gout Dx *
Joints Affected *
Required
Average # of Flares in the Past Year *
Required
Uric Acid Level
Urate Crystals in SF
Clear selection
Medications Initiated on First Consult at PGH *
Pls check all that apply
Required
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