Do not mail – bring day of appointment

DO NOT MAIL – BRING DAY OF APPOINTMENT Date of First Appointment: _______ /_______ /________ Name: _____________________________________________________________________________________ Birth date: ______ /_______ /_______ Last First Middle Initial Maiden Month Day Year Address: ________________________________________________________________________ Age: __________ Sex: ________ F __________ M Street Apt. # ___________________________________________________________________________ Telephone: Home ( ) __________________ City State Zip Work ( ) __________________ Referred here by: (Check one) _________ Self _________ Family _________ Friend _________ Doctor _________ Other Health Professional Name of person making referral: _________________________________________________________________________________________________ The name of the physician providing you general medical care: ________________________________________________________________________ Do you have an orthopedic surgeon? __________ Yes ____________ No If yes, name: ____________________________________________ Briefly describe your present symptoms: ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Date symptoms began (approximate) _______________________________ Diagnosis given? (Please list) _____________________________________ 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: ______________________________________________________________ ______________________________________________________________________________________________________________________________ RHEUMATOLOGIC (ARTHRITIS) HISTORY At any time have you or a blood relative had any of the following? (Check if “Yes”) Yourself ________ Arthritis (type unknown) ________________________ ___________ Lupus or “SLE” _______________________ ________ Rheumatoid Arthritis ________________________ ___________ Childhood arthritis _______________________ Other arthritis conditions: ________________________________________________________________________________________________________ As you review the following list, please check any of those problems with apply to you. ________ Color changes of hands or feet in cold ________ Difficulty in breathing at night ________ Sensitivity or pain of hands and/or feet List joints affected in the last 6 months: ________ Vomiting of blood or coffee ground ________Stomach pain relieved by food or milk ________Feels like something in your eye o you drink coffee? ______________________ Has anyone ever told you to cut down on your Do you use drugs for reasons that are not ________Getting up at night to pass urine medical? If so, pelase list __________________ _________________________________________ _________________________________________ How many pillows do you use to sleep on each night? ___________________________________ Date of last eye examination _________________ Date of last chest X-Ray _____________________ Date of last Tuberculosis Test ________________ Date of last Pap Smear: ______________________ Bleeding after menopause: ____Yes ____No PAST PERSONAL HISTORY Do you or have you had: (check if “yes”) Cancer ___________________ Other Significant Illness (Please List): ___________________________________________________________________________________________________ Previous Operations: Type 1) ________________________________________________________ ___________ _____________________________________ __________________ 2) ________________________________________________________ ___________ _____________________________________ __________________ 3) ________________________________________________________ ___________ _____________________________________ __________________ 4) ________________________________________________________ ___________ _____________________________________ __________________ 5) ________________________________________________________ ___________ _____________________________________ __________________ 6) ________________________________________________________ ___________ _____________________________________ __________________ 7) ________________________________________________________ ___________ _____________________________________ __________________ Any previous fractures? _______ No ________ Yes Describe _____________________________________________________________________________ Any other serious injuries? _______ No ________ Yes Describe _____________________________________________________________________________ FAMILY HISTORY: Number of Brothers ______________ Number Living ______________ Number Deceased ______________ Number of Sisters ______________ Number Living ______________ Number Deceased ______________ Number of Children ______________ Number Living ______________ Number Deceased ______________ List ages of each ______________ Serious illnesses of Children: ___________________________________________________________________________________________________________ Do you know of any blood relative who has or has had: (check and give relationship): Cancer __________________ Heart Disease ____________________ Rheumatic fever ____________________ Tuberculosis ____________________ Leukemia ________________ High Blood Pressure ________________ Epilepsy ____________________________ Diabetes ________________________ Stroke ___________________ Bleeding tendency _________________ Asthma _____________________________ Goiter __________________________ Colitis ___________________ Alcoholism _______________________ MARITAL STATUS: _______ Never Married _______ Married _______ Divorced _______ Separated Major Illnesses: __________________________ _______________ EDUCATION: (circle highest level attended) Grade School: Graduate School ________________________________ Occupation: _______________________________________________________ Number of hours worked/average per week ________________________ Do you have stairs to climb? __________ Yes ____________ No If yes, how many? _______________________________________ Number of people in household: _____________ Relationship, and age of each? _____________________________________________________________ Who does the most housework? _______________________________ Who does the most shopping? ______________________________________ On the scale below, circle a number which best describes your situation; Most of the time, I function…. 1 Because of health problems, do you have difficulty: (please check the appropriate response for each questions) Using your hands to grasp small objects? (buttons, toothbrush, pencil, etc.) …………………………………………… ____________ ____________ ____________ Walking? ………………………………………………………………………………………………………………………………………………. ____________ ____________ ____________ Climbing stairs? ……………………………………………………………………………………………………………………………………. ____________ ____________ ____________ Descending stairs? ………………………………………………………………………………………………………………………………. ____________ ____________ ____________ Sitting down? ………………………………………………………………………………………………………………………………………. ____________ ____________ ____________ Getting up from the chair? ……………………………………………………………………………………………………………………. ____________ ____________ ____________ Touching you feet while seated? …………………………………………………………………………………………………………… ____________ ____________ ____________ Reaching behind your back? …………………………………………………………………………………………………………………. ____________ ____________ ____________ Reaching behind your head? …………………………………………………………………………………………………………………. ____________ ____________ ____________ Dressing yourself? ………………………………………………………………………………………………………………………………. ____________ ____________ ____________ Going to sleep? ……………………………………………………………………………………………………………………………………. ____________ ____________ ____________ Staying asleep due to pain? …………………………………………………………………………………………………………………. ____________ ____________ ____________ Obtaining restful sleep? ………………………………………………………………………………………………………………………… ____________ ____________ ____________ Bathing? ………………………………………………………………………………………………………………………………………………. ____________ ____________ ____________ Eating? ………………………………………………………………………………………………………………………………………………… ____________ ____________ ____________ Working? ……………………………………………………………………………………………………………………………………………… ____________ ____________ ____________ Getting along with other 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 item) ……………………………………………………… ____________ ____________ ____________ What is the hardest thing for you to do? _______________________________________________________________________________________________ Are you receiving disability? ………………………………………………………………………………………………………………………………………. ____________ Yes ____________ No Are you applying for disability? …………………………………………………………………………………………………………………………………. ____________ Yes ____________ No Do you have a medically related lawsuit pending? ……………………………………………………………………………………………………. ____________ Yes ____________ No MEDICATIONS DRUG ALLERGIES: _________ No __________ Yes To What? __________________________________________________________________ ___________________________________________________________________________________________________________________________________ Type of reaction? ____________________________________________________________________________________________________________________ Present: (List any medications you are taking at this time. Include items such as aspirin, vitamins, laxatives, calcium supplements, etc.) Past: 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.

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