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APLAR Sjögren’s Syndrome Registry – Form 2
"
*
" indicates required fields
Step
1
of
3
33%
Form 2: Complaints and evaluation/criteria features for SS
Centre
*
Serial No
*
Consent Signed
*
Yes
No
Date of Recruitment
*
DD slash MM slash YYYY
Age at Recruitment
*
Name
*
First
Last
Female
*
Male
Female
Prefer not to respond
Hospital ID
*
First presenting complaint
*
Dry eyes
Dry mouth
Non-sicca
Date of first non-sicca
MM slash DD slash YYYY
Date of first sicca
MM slash DD slash YYYY
For non-sicca, which domain:
Joint
Muscle
Skin
Glandular pain or swelling
Renal
Lung
Neurology
Haemat
Fever
weight loss
Fatigue
Lab abnormality
CHB
Fatigue-fibromyalgia
Others
Speciality of first contact
Ophthal
Dentist
Medicine
Rheumat
Neuro
Nephro
Uro
Endo
Emergency
ICU
Ortho
Haemat
Pulmonary
Surgery
ENT
Paed
Obg
Psych
Cardiology
Dermatology
Alternative Medicine
Other
First Diagnosis received by the Patient
Did the patient have occult sicca at the time of the first non-sicca complaint?
*
Yes
No
Please provide details on the occult sicca
Was occult sicca elicited at the time of the first non-sicca complaint?
Yes
No
Please provide details
Has the patient consulted ophthalmology/dentist prior to the first non-sicca complaint?
Yes
No
Please provide details
Date at Dx of SS
MM slash DD slash YYYY
Fulfils ACR/EULAR 2016 criteria
Yes
No
Fulfils AECG
Yes
No
SS Criteria features
Eye subjective
Positive
Negative
Not Available
Method
Oral subjective
Positive
Negative
Not Available
Method
MSG bx
Positive
Negative
Not Available
Focus score
Anti-SSA
Positive
Negative
Not Available
Anti-SSA - Methodology/Kit:
Anti-SSA Negative - Titre(cut-off)/Intensity:
Anti-Ro52
Positive
Negative
Not Available
Anti-Ro52 - Methodology/Kit:
Anti-Ro52 Negative - Titre(cut-off)/Intensity:
Anti-Ro60
Positive
Negative
Not Available
Anti-Ro60 - Methodology/Kit:
Anti-Ro60 Negative - Titre(cut-off)/Intensity:
Anti-SSB
Positive
Negative
Not Available
Anti-SSB - Methodology/Kit:
Anti-SSB Negative - Titre(cut-off)/Intensity:
Immunological Assays at SS Diagnosis
ANA
Titre(cut-off)
Not Available
ANA Methodology/Kit:
RF
Titre(cut-off)
Not Available
RF Methodology/Kit:
C3
Value (cut-off)
Not Available
C3 Methodology/Kit:
C4
Value (cut-off)
Not Available
C4 Methodology/Kit:
Cryo
Positive
Negative
Not Available
IgG
Value (cut-off)
Not Available
IgG Methodology/Kit:
Clonality
Not Available
Other Antibodies
Not Available
Vitamin D
Value (cut-off)
Not Available
Vitamin D Methodology/Kit:
Viral Serology
Positive
Negative
Not Available
HBV
HCV
HIV
Albumin/ Globulin Value
Enter NA if value is not available
Albumin/ Globulin
Not Available
SGUS
SGUS data is not available
Yes
R Parotid
L Parotid
R Submandibular
L Submandibular
SGUS : OMERACT
Grade 0 (Normal parenchyma)
Grade 1 (Mild inhomogeneity without anechoic or hypoechoic areas and hyperechogenic bands)
Grade 2 (Moderate inhomogeneity with focal anechoic or hypoechoic areas)
Grade 3 (Severe inhomogeneity with diffuse anechoic or hypoechoic areas occupying the entire gland or a fibrous gland)
Cut-off score ≥2 in at least one gland; ≥7 in all 4 glands