Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth *

MM

DD

YYYY

Does your pain wake you at night? *

Yes

No

Sometimes

How would you describe your pain pattern throughout the day *

You can pick more than one option

Sore/stiff in the morning but eases within minutes of moving

Sore/stiff in the morning but eases within around 20 minutes

Sore/stiff in the morning but eases within around an hour

Ok in the morning, but gets worse as the day goes on

Worse when doing certain things (please make sure you have included these in the 'What makes your pain worse' section above)

Eases with movement, gets worse if not doing anything for a long time

Gets easier with movement, but worse if doing too much

Worse at night

Do you have a history of cancer? *

Yes

No

Has anyone in your family had cancer *

Yes

No

Do you have any thyroid conditions *

Yes

No

Do you have any heart conditions *

This includes high blood pressure and raised cholesterol

Yes

No

Do you have any rheumatoid conditions (such as rheumatoid arthritis)? *

Yes

No

Does anyone in your family have a rheumatoid condition? *

Yes

No

Are you epileptic? *

Yes

No

Do you have asthma? *

Yes

No

Are you a diabetic? *

Yes

No

Have you taken any steroids in the last 12 weeks (prescription or otherwise)? *

Yes

No

Have you ever had tuberculosis (TB)? *

Yes

No

Have you ever had a deep vein thrombosis (DVT) *

Yes

No

Have you ever had surgery? *

Yes

No

Have you ever had any fractures (broken bones) *

Yes

No

Have you had any antibiotics in the last 12 months? *

Yes

No

Have you ever been involved in a major accident? *

Yes

No

Do you smoke? *

Yes

No

If you answered no, did you previously smoke? *

Yes

No

Do you drink alcohol? *

Yes

No