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APLAR Sjögren’s Syndrome Registry – Form 7
"
*
" indicates required fields
Step
1
of
3
33%
Treatment at recruitment (Systemic, ocular, oral)
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
*
Systemic Treatment (@ SS Recruitment)
Drug
Glucocorticoids
HCQ
Azathioprine
Mycophenolate
MTX
Leflunomide
RTX
Cyclophosphamide
Tofacitinib
Alkali
Potassium
Others
Glucocorticoids
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
HCQ
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Azathioprine
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Mycophenolate
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
MTX
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Leflunomide
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
RTX
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Cyclophosphamide
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Tofacitinib
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Alkali
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Potassium
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Others
Drug
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Eye Treatment (@ SS Recruitment)
Eye Treatment Drugs
Tear Supplements
Tear Gel
Topical GC
Topical Cyclosporine
Topical mucolytic
Serum eye drops
Punctal plugs
Scleral contact lens
Corneal graft
Oral Pilocarpine
Others
Tear Supplements
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Tear Gel
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Topical GC
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Topical Cyclosporine
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Topical mucolytic
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Serum eye drops
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Punctal plugs
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Scleral contact lens
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Corneal graft
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Oral Pilocarpine
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Others
Drug
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Oral Treatment (@ SS Recruitment)
Oral Treatment Drug
Salivary supplements
Oral Pilocarpine
Topical Anti-fungals
Topical Fluoride
Filling
Crown
Root canal treatment
Extraction
Others
Salivary supplements
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Oral Pilocarpine
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Topical Anti-fungals
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Topical Fluoride
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Filling
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Crown
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Root canal treatment
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Extraction
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove
Others
Drug
Dosage
Time Period
Response - Partial, Complete, NIL
Adverse Event
Add
Remove