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Register for HelpPayRA

Fill out this form below to become a registered user on HelpPayRA.com.
Being a registered user gives you access to web site descriptions, links and other exclusive content. You'll also receive updates and news regarding rheumatoid arthritis and its treatments.

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By providing this information, you are giving UCB and its business partners permission to send you information regarding your disease as well as information on other related treatments, products and services, and for marketing and informational purposes. You understand that UCB or its business partners will not sell your name, address, e-mail address, or any other information to another party for their own marketing use. You may remove yourself from the mailing list at any time and review the privacy policy at www.cimzia.com/unsubscribe.



Please answer the following questions about your condition

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*On a scale of 1-5, how severe would you rate your RA, with 1 being low and 5 being high?

   (1) Low severity
   (2) Low/Mid severity
   (3) Mid severity
   (4) Mid/High severity
   (5) High severity

*How well have your RA symptoms been controlled during the past 60 days?

   Not controlled at all
   Poorly controlled
   Somewhat controlled
   Well controlled
   Completely controlled

*Are you currently taking a perscription?

   Yes   No

*Are you currently being treated by a Rheumatologist?

   Yes   No

*Have you ever taken any of the following medications for your RA?

  Current Med Former Med
DMARDs or methotrexate
Actemra® (tocillzumab)
Cimzia® (certolizumab pegol)
Enbrel® (etanercept)
Humira® (adalimumab)
Orencia® (abatacept)
Remicade® (infliximab)
Rituxan® (rituximab)
Simponi®
 

Actemra®, Cimzia®, Enbrel®, Humira®, Orencia®, Remicade®, Rituxan®, Simponi® are trademarks of their respective companies.

I am not taking and have not taken any of the above medications

*How long have you been taking your current treatment for RA?

   Less than 3 months    4-6 months    7-12 months    More than 1 year

Please continue answering the following questions regarding your friend or family member.

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How involved are you in the treatment decisions for the person you care about with RA?

   Not at all    Somewhat involved    Very involved

Rate the following on a scale of 1-7.
1 = Completely disagree
4 = Neither agree nor disagree
7 = Completely agree

I feel like the person I care about is coping pretty well with RA.

   1    2    3    4    5    6    7

I feel that I can make a difference when I provide the person I care about with information about rheumatoid arthritis.

   1    2    3    4    5    6    7

I have a lot of tools and resources for managing rheumatoid arthritis that I can share with someone I know who has RA.

   1    2    3    4    5    6    7




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