Name

Birth Date

Age

Gender

Male Female

Residency

--< Select >-- Cairo Giza Alexandria Port Said Suez Demiatt Dakahlia Sharkia Qalyoubia Kafr Shaikh Gharbia Menouffia Behaira Ismaillia Beni Suif Fayoum Minia Assuit Sohag Qena Asswan Luxor Al Bahr Al Ahmar Al Wadi Al Gaddid Matrouh N. Sinai S. Sinai Other Country

Occupation

Weight (kg)

Height (m)

BMI (Body Mass Index)

Smoking

Yes No

Informed Consent

Diseases (MTX Applied for)

--< Select >-- Rheumatoid Arthritis SLE Systemic Sclerosis JIA Ankylosing Spondylitis Psoriatic arthritis Enteropathic arthritis Gout Pseudogout Polymyositis Dermatomyositis MCTD Sjogren's $ Antiphospholipid $ Adult onset Still's disease Giant Cell Arteritis (GCA) Takayasu Arteritis (TA) Polyarteritis nodosa (PAN) Kawasaki Wegner disease (GPA) Churg Strauss disease (EGPA) Microscopic Polyangitis (MPA) Behcet Syndrome FMF Amyloidosis

Dose

Duration of treatment

Interval between treatment doses

Response

Excellent Good Poor No response

Patient Compliance

Excellent Good Poor

Adherence to MTX

Excellent Good Poor

Bone Marrow suppression

Yes No

Elevated Liver Enzymes (ALT& AST)

Yes No

Pneumonitis

Yes No

Teratogenicity

Yes No

Stomatitis

Yes No

MTX Nodulosis

Yes No

Megaloblastic Anemia

Yes No

Primary failure

Yes No

Switched to (after primary failure)

Secondary failure

Yes No

Switched to (after secondary failure)