Author: Dana Bell

RHEUMATOLOGY

Patient History Form

Date of first appointment: _____/_____/______ Time of appointment:_____________ Birthplace:______________________
Name: Birthdate:_____/_____/__________
Address: Age:_______________ Sex: F M
Telephone: Home ( )
MARITAL STATUS: Never Married Married Divorced Work ( )
Separated Widowed Cell ( )
Spouse/Significant Other: Alive/Age_______ Deceased/Age_______ Major Illnesses
EDUCATION (highest level attended): Occupation:
Number of hours worked/average per week Referred here by: (check one) Self Family Friend Doctor Other Health Professional
Name of Person Making Referral:
Name of your Primary Medical Care Provider:
Do you have an Orthopedic Surgeon? No Yes If yes, name:
Previous Rheumatologist seen:

Briefly describe your present symptoms:
Date symptoms began (approximate):
Diagnosis:
Previous treatment for this problem (include physical therapy, surgery, and injections; medications to be listed later)
Please list the names of other practitioners you have seen for this problem:

PLEASE SHADE ALL LOCATIONS OF YOUR PAIN FOR THE PAST WEEK ON THE BODY FIGURES AND HANDS

SYSTEMS REVIEW
As you review the following list, please check any of those problems which have significantly affected you.
Date of last mammogram_____/_____/_______ Date of last eye exam_____/_____/_______Date of last chest x-ray_____/_____/_______
Date of last bone desitometry_____/_____/_______ Where was it done? __________________ Results?_____________________________
Date of last Tuberculosis test_____/_____/_______ Results?_____________________

Constitutional
Recent weight gain. Amount _______
Recent weight loss. Amount _______
Fatigue
Weakness
Fever
Eyes
Pain
Redness
Loss of vision
Double or blurred vision
Dryness
Feels like something in eye
Itching eyes
Ears/Nose/Mouth/Throat
Ringing in ears
Loss of hearing
Nosebleeds
Loss of smell
Dryness in nose
Runny nose
Sore tongue
Bleeding gums
Sores in mouth
Loss of taste
Dryness in mouth
Frequent sore throat
Hoarseness
Difficulty swallowing
Cardiovascular
Nausea
Vomiting blood/coffee ground material
Stomach pain relieved by food/milk
Jaundice
Increasing constipation
Persistent diarrhea
Blood in stools
Black stools
Heartburn
Genitourinary
Difficult urination
Pain/burning with urination
Blood in urine
Cloudy urine
Pus in urine
Discharge from penis/vagina
Getting up at night to urinate
Vaginal dryness
Rash/ulcers
Sexual difficulties
Prostate trouble
For Women Only:
Age when periods began:__________
Are periods regular? ______yes______no
How many days apart?_____________
Date of last period?_____/_____/____
Date of last pap?_____/_____/______
Bleeding after menopause? _____yes_____no
Number of pregnancies:__________
Number of miscarriages:________
Musculoskeletal
Morning stiffness
Lasting how long?
______Minutes ______Hours
Joint pain
Muscle weakness
Muscle tenderness
Joint swelling
List joints affected in the last 6 months:
Integumentary (skin/breast)
Easy bruising
Redness
Rash
Hives
Sun sensitivity
Tightness
Nodules/bumps
Hair loss
Color changes of hands/feet in the cold
Neurological
Headaches
Dizziness
Fainting
Muscle spasms
Loss of consciousness
Sensitivity/pain of hands/feet
Memory loss
Night sweats
Psychiatric
Excessive worries
Anxiety
Easily losing temper
Depression
Agitation
Difficulty falling asleep
Difficulty staying asleep
Endocrine
Excessive thirst
Hematologic/Lymphatic
Swollen glands
Tender glands
Anemia
Bleeding tendency
Transfusion/when?___________
Allergy/Immunology
Frequent sneezing
Increased susceptibility to infection

SOCIAL HISTORY
Do you drink caffeinated beverages? Yes No
Cups/glasses per day?
Do you smoke? Yes No Quit — How long ago?
Do you drink alcohol? Yes No Number per week
Has anyone ever told you to cut down on your drinking?
Yes No
Do you use street drugs? Yes No
If yes, please list:
Do you exercise regularly? Yes No
Type Amount per week
Average hours of sleep per night?
Do you get enough sleep at night? Yes No
Do you wake feeling rested? Yes No

PAST MEDICAL HISTORY
Do you now or have you ever had: (check if “yes”)

Cancer
Goiter/Thyroid
Cataracts
Anxiety/Depression
Bad Headaches
Kidney disease
Heart problems
Leukemia
Diabetes
Stomach ulcers
Jaundice/Liver disease/Hepatitis B, C
HIV/AIDS
Lung Problems
Stroke
Epilepsy
Rheumatic fever
Colitis
Psoriasis
High blood pressure
Tuberculosis
Blood clot

Other significant illnesses (please list)
Natural or Alternative Therapies (chiropractic, magnets, massage, over-the-counter preparations, etc.)

PREVIOUS OPERATIONS
Type Year Reason
1
2
3
4
5
6
7
Any previous fractures? Yes No Describe:
Any other serious injuries? Yes No Describe:

FAMILY HISTORY: IF LIVING IF DECEASED
Age Condition of Health Age at Death Cause
Father
Mother
Number of Siblings Number living Number deceased
Number of children Number living Number deceased List ages of each

RHEUMATOLOGIC (ARTHRITIS) HISTORY
At any time have you or a blood relative had any of the following? (check if “yes”)
Yourself Relative Name/Relationship Yourself Relative Name/Relationship
Arthritis (unknown type) Lupus or “SLE”
Osteoarthritis Rheumatoid Arthritis
Gout Ankylosing Spondylitis
Childhood Arthritis Osteoporosis
Other arthritis conditions:

MEDICATIONS
Drug Allergies: No Yes To What?
Type of reaction:

PRESENT MEDICATIONS (List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium, and other OTC items.)

Name of Drug	Dose (include strength & number of pills per day)	How long have you taken this medication	Please check: Helped? / A Lot Some Not At All
1.
2.
3.
4.
5.
6.
7.
8.
9.
10

PAST MEDICATIONS: Please review this list of “arthritis” medications. As accurately as possible, try to remember which medications you have taken, how long you were taking the medication, the results of taking the medication and list any reactions you may have had. Record your comments in the spaces provided.

Drug names/Dosage	Length of time	Please check: Helped? / A Lot Some Not at all			Reactions
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Circle any you have taken in the past / Ansaid (flurbiprofen) Arthrotec (diclofenac + misoprostil) Aspirin (including coated aspirin) Celebrex (celecoxib) Clinoril (sulindac) Daypro (oxaprozin) Disalcid (salsalate) Dolobid (diflunisal) Feldene (piroxicam) Indocin (indomethacin) Lodine (etodolac) Meclomen (meclofenamate) Motrin/Rufen(ibuprofen) Nalfon (fenoprofen) Naprosyn (naproxen) Oruvail (ketoprofen) Tolectin(tolmetin) Trilisate (choline magnesium trisalicylate) Vioxx (rofecoxib) Voltaren (diclofenac) Mobic (Meloxicam)
Pain Relievers
Acetaminophen (Tylenol)
Codeine (Tylenol #3/Tylenol #4)
Propoxyphene (Darvon/Darvocet)
Oxycodone (Oxycontin)
Opana (Oxymorphone)
Hydrocodone (Norco/Vicodin)
Morphine (MS Contin)
Disease Modifying Antirheumatic Drugs (DMARDS)
Hydroxychloroquine (Plaquenil)
Methotrexate (Rheumatrex)
Azathioprine (Imuran)
Sulfasalazine (Azulfidine)
Cyclophosphamide (Cytoxan)
Cyclosporine A (Sandimmune or Neoral)
Xeljanz
Etanercept (Enbrel)
Secukinumab (Cosentyx)
Infliximab (Remicade)

Drug names/Dosage	Length of time	Please check: Helped? / A Lot Some Not at all			Reactions
Adalimumab (Humira)
Golimumab (Simponi)
Abatacept (Orencia)
Rituximab (Rituxan)
Tocilizumab (Actemra)
Certolizumab (Cimzia)
Ixekizumab (Taltz)
Sarilumab (Kevzara)
Apremilast (Otezla)
Osteoporosis Medications
Estrogen (Premarin, etc)
Alendronate (Fosamax)
Raloxifene (Evista)
Calcitonin Injection or Nasal (Miacalcin, Calcimar)
Risedronate (Actonel)
Ibandronate (Boniva)
Denosumab (Prolia)
Zoledronic Acid (Reclast)
Teriparatide (Forteo)
Gout Medications
Probenecid (Benemid)
Colchicine (Colcrys)
Allopurinol (Zyloprim/Lopurin)
Febuxostat (Uloric)
Other Medications
Tizanidine (Zanaflex)
Cyclobenzaprine (Flexeril)
Gabapentin (Neurontin)
Pregabalin (Lyrica)
Duloxetine (Cymbalta)
Amitryptyline (Elavil)
Tamoxifen (Nolvadex)
Cortisone (Prednisone)
Hyalgan/Synvisc/Euflexxa Injections
Herbal or Nutritional Supplements
Please list supplements:

ACTIVITIES OF DAILY LIVING
Do you have stairs to climb? Yes No If yes, how many?
How many people in your household? Relationship and age of each
Who does most of the housework? Who does most of the shopping? Who does most of the yardwork?
On the scale below, circle a number which best describes your situation: Most of the time, I function…….

1

VERY POORLY

2

POORLY

3

OK

4

WELL

5

VERY WELL

Because of health problems, do you have difficulty:
(Please check the appropriate response for each question)

USUALLY SOMETIMES NO

Using your hands to grasp small objects? (buttons, toothbrush, pencil, etc.)
Walking?
Climbing Stairs
Descending stairs
Sitting down
Getting up from chair
Touching your feet while seated?
Reaching behind your back?
Dressing yourself?
Going to sleep?
Staying asleep due to pain?
Obtaining restful sleep?
Bathing?
Eating?
Working?
Getting along with family members?
In your sexual relationship?
Engaging in leisure time activities?
With morning stiffness?
Do you use a cane, crutches, a walker or a wheelchair? (circle one)
What is the hardest thing for you to do?
Are you receiving disability?
Are you applying for disability?
Do you have a medically related lawsuit pending?

Patient’s Name_______________________________Date______________________Physician’s Initials__________________