<p>______MANCHESTER UVEITIS CLINIC</p><p>HEALTH REVIEW ______</p><p>Surname: Review date: Patient Forename: Label Uveitis Diagnosis: Hosp. No: Systemic Diagnosis:</p><p>Section 1: Current Systemic medication for Inflammatory Disease</p><p>Drug, Current dose Date started Treatment duration Complete sections: (m) Prednisolone 2, 3, 4, 10 Azathioprine 2, 6, 8, 9</p><p>Ciclosporin 2, 7, 8, 9, 10</p><p>Methotrexate 2, 5, 8 Mycophenolate 2, 6, 8, 9 Tacrolimus 2, 7, 8, 9, 10 Other...... Discontinued (circle): AZA CYC MTX MYC TAC</p><p>Section 2: Identify other medication which may cause interactions </p><p>NSAID (Cyc,Tac ) Rifampicin (Cyc,Tac,Pred ) Allopurinol (Aza) Comment:</p><p>1 NB Risk of peptic ulcer Isoniazid (Cyc,Tac ) Indomethacin (Aza)</p><p> if also on Prednisolone Phenytoin (Cyc,Tac ) Septrin (Aza)</p><p>Verapamil (Cyc,Tac ) Carbamazepine (Cyc,Tac ) Aciclovir (Myc)</p><p>Nicardipine (Cyc,Tac ) Sulphadiazine (Cyc,Tac ) Antacids (Myc)</p><p>Nifedipine (Cyc,Tac ) Antifungals (Cyc,Tac ) Diltiazem (Cyc,Tac )</p><p>Section 3: Prednisolone (Ref GF1 Protocol; Prednisolone)</p><p>Current weight: Starting weight: Weight gain:</p><p>Assess symptoms & examine: Comments: Action required:</p><p>Bruising tendency? Y N Skin striae? Y N Hirsute/Cushingoid? Y N</p><p>Dyspepsia? Y N On H2 antagonist?: On PPI?: Other? (Specify):</p><p>Section 4: Bone Health (Ref GF1 Protocol; Prednisolone)</p><p>Risk Factor Assessment Action required:</p><p>Smoker? Y N ...... cigs/day or...... Alcohol intake? ...... units/wk</p><p> Periods irregular? Y N Comment: Past amenorrhoea? Y N Oophorectomy? Y N On HRT? Y N Post-menopausal? Y N Preg on treatment? Y N</p><p>Past anorexia/Vegan? Y N Comment: Weight-bearing exercise? ...... miles/wk or...... </p><p>Arthritis? Y N Limits mobility? Y N</p><p>2 Diabetic? Y N Duration ...... yrs Other ?...... </p><p>Bone density assessments DEXA first date: / / T-score Lumbar spine ...... T-score Femoral neck ...... DEXA last date: / / T-score Lumbar spine ...... T-score Femoral neck ...... Next DEXA due? Action taken: Prophylaxis</p><p>Calcichew D3F? Y N Dose...... Duration...... Action: Didronel PMO? Y N Dose...... Duration...... Action: Fosamax? Y N Dose...... Duration...... Action: Supervision</p><p> c/o Uveitis Clinic only? Y N c/o Dr Davies Dr Selby Action:</p><p>Section 5: Methotrexate (Ref GF1 Protocol: Methotrexate)</p><p>Adverse symptoms and safety checks Action taken</p><p>Stomatitis, ulcers? Y N Current Folate dose: Advise no NSAID, no alcohol</p><p>GIT pain, diarrhoea? Y N Using contraception?  Y N</p><p>Cough, chest pain? Y N Other (specify): Assess blood profile within last 3 months Action taken</p><p>Abnormal liver function? Y N Abnormal WCC? Y N</p><p>Anaemia? Y N Abnormal Platelets? Y N</p><p>Section 6: Azathioprine (Ref GF1 Protocol: Azathioprine) Mycophenolate mofetil (Ref GF1 Protocol: Mycophenolate)</p><p>Adverse symptoms and safety checks Action taken</p><p>Bruising, gum bleeding? Y N Using contraception?  Y N</p><p>GIT symptoms? Y N Hair loss? Y N Other (specify):</p><p>3 Assess blood profile within last 3 months Action taken</p><p>Abnormal liver function? Y N Lymphocyte count:</p><p>Anaemia? Y N Macrocytosis? Y N</p><p>Section 7: Ciclosporin (Ref GF1 Protocol: Ciclosporin) Tacrolimus (Ref GF1 Protocol: Tacrolimus)</p><p>Adverse symptoms and safety checks Action taken</p><p>Tremor, paraesthesiae, cramps, Using contraception?  Y N Advise no NSAID other neuro symptoms? Y N</p><p>Hair: excess? (Cyc) Y N Gum disease/caries? Y N Hair loss? (Tac) Y N Dental hygience/checks? Y N</p><p>GIT symptoms? Y N Other (specify): Assess blood profile within last 3 months Action taken</p><p>Normal liver function? Y N WCC normal? Y N</p><p>Anaemia? Y N Hyperglycaemia? (Tac) Y N Creatinine Before: Creatinine Now :</p><p>Section 8: Infection (Ref GF1 Protocols: Azathioprine, Cyclosporin, Mycophenolate, Tacrolimus)</p><p>Infections since last review, and comments Action required:</p><p>Thrush? Y N Warts? Y N</p><p>Hospital admission? Y N Other? (Specify) How many antibiotic courses in last year? Immunisation and infection history</p><p>Definite chickenpox? Y N VZV serology +ve -ve</p><p>Measles immunised? Y N BCG immunised? Y N</p><p>TB history? Y N On Septrin prophylaxis? Y N</p><p>Section 9: Malignancy (Ref GF1 Protocols: Azathioprine, Cyclosporin, Mycophenolate, Tacrolimus)</p><p>4 Self-examination Suspicious lesions Action taken</p><p> Regular breast examination? Y N Inform NPJ. Comment: Give pamphlet </p><p> Skin self- examination? Y N “immunosuppression and </p><p> Glands neck/axilla/groin? Y N skin cancer” Other?:</p><p>Section 10: Cardiovascular (Ref GF1 Protocol: Cardiovascular Disease)</p><p>Assessment of cardiovascular risk 1. Blood pressure - measure BP today / Average last 3 BPs = / (On antihypertensive? 1. 2. Specify): 2. Lipid profile - blood taken Total cholesterol (TC) = Ratio TC/HDL = HDL = (On statin? Specify):</p><p>3. Diabetes - urinalysis/history IDDM NIDDM Diabetic Y N (On treatment? Specify):</p><p>4. Smoking Smoker Y N 5. Assess coronary risk Use Charts 2 & 3 Low / Moderate / High Body mass index (Chart 1) Height...... Weight...... OK / Obese / Severe obese Additional risks?: Alcohol intake >28 units/wk Y N Sedentary Y N Action taken: New treatment required: informed of: GP to be</p><p>5</p>