Alkem

Patient No *

Patient Initials *

Date of Enrollment *

Patient ID

Age (in Years) *

Gender *

Male Female Other

Date of Diagnosis *

Disease Duration (years)*

Previous Treatment History *

Co-morbidities (if any)

Concomitant Medications

Start Date of Adalimumab Treatment *

Dosage Regimen *

40 mg every other week Any Other

Duration of Treatment (months) *

Reason for Treatment Discontinuation (if applicable)

Baseline Pain Intensity *

VAS

Baseline Morning Stiffness Duration (minutes/hours) *

Baseline Sacroiliac Joint Radiograph Grade (Modified New York Criteria)

Grade 0 Grade 1 Grade 2 Grade 3 Not Available

Baseline Spinal Radiograph Findings

Follow-up Sacroiliac Joint Radiograph Grade

Grade 0 Grade 1 Grade 2 Grade 3 Not Available

Follow-up Spinal Radiograph Findings

Baseline CRP Level (mg/L)

Baseline ESR Level (mm/hour)

Follow-up CRP Level (mg/L) (if available)

Follow-up ESR Level (mm/hour) (if available)

Adverse Events*

Yes No

Severity *

Mild Moderate Severe

Adverse Event Description*

Date of Onset*

Action Taken*

Treatment Modification Discontinuation Any other

Demographic Information