Shanahan Rheumatology & Immunotherapy, PLLC

Transcription

1 Personal Information: Shanahan Rheumatology & Immunotherapy, PLLC Date: Last Name: First Name: Middle Initial: Date of Birth: - - Marital Status: Street Address: City: Zip: Home Ph: ( ) - Work Ph: ( ) - Cell Ph: ( ) - Address: Emergency Contact Information: Name: Relation: Phone: ( ) - Physician Information: Primary Care Physician Name: Phone: ( ) - Fax: ( ) - Referring Physician: (If different from primary care physician) Name: Phone: ( ) - Fax: ( ) - Pharmacy Information: Pharmacy Name: Phone: ( ) - Location/Address: If Patient is a Minor: Parent/Guardian Last Name: First Name: Date of Birth: - - Marital Status: Street Address: City: Zip: Home Ph: ( ) - Work Ph: ( ) - Cell Ph: ( ) - Individuals Authorized to Receive Patient Information (please do not include doctors listed above) : Name: Relation: Name: Relation: Authorization for Release of Information: I give my permission to Shanahan Rheumatology and Immunotherapy to discuss my care with the individuals listed on the demographics page submitted. This authorization is valid from today until revoked in writing as long as I am a patient of this office. I understand that I may authorize additional recipients at any time. Signature of Responsible Party: Date: Time: WakeMed Brier Creek Health Park ٠10208 Cerny St, Suite 301, Raleigh, NC, ٠ (919)

2 Shanahan Rheumatology & Immunotherapy, PLLC Patient Demographics Form Name: Date: Due to federal government regulations, we are now required to collect data on Race, Ethnicity and Language. If you prefer not to report that information, you may choose I Decline to Report. (Please Check ONE in EACH CATEGORY that applies) I Decline to Report R A C E E T H N I C I T Y PREFERRED LANGUAGE More Than One Race I Decline to Report I Decline to Report Black or African American Native Hawaiian Hispanic or Latino Not Hispanic or Latino English Spanish Asian American Indian or Alaskan Native Other Pacific Islander Undefined Undefined Other (Please fill in the blank) White For office use only: Unreported For office use only: Unreported For office use only: Unreported

3 Medical History New Patient Patient Name: Patient MRN: Date: Instructions: Please fill out this form as completely as possible. Check boxes if the statement applies to you Obstetrical history (for women) Medical History List other medical Ever pregnant high blood pressure problems below: # of pregnancies(regardless of delivery) high cholesterol Miscarriages thyroid disease # of miscarriages heart attack How far along was the pregnancy? stroke heart rhythm problems diabetes menopause Date of last period: use insulin Medically discontinued pregnancies do not use insulin # psoriasis Ectopic pregnancies # emphysema or COPD Blood clotting history blood clot Tuberculosis history # of clots: treated for tuberculosis (Tb) Where were did they occur? exposed to person with Tb history of positive PPD or tyne test treated with INH history of avascular necrosis (osteonecrosis) How many months? Osteoporosis history Surgical history List other surgeries below: diagnosed with osteoporosis Treated yes no cholecystectomy (gall bladder) fracture (broken bone) appendectomy # of fractures: tonsillectomy Where did you fracture? caesarian section (C-section) hysterectomy Mother and/or father fractured a hip (circle which one) removed both ovaries Bone density (DEXA scan) has been performed Coronary artery bypass grafting date of last DEXA carotid endartectomy where was the DEXA performed? Family history List relative(s) affected by Social history Disease each disease: currently smoke cigarettes Rheumatoid arthritis # of packs per day on average Lupus previously was a smoker of cigarettes Scleroderma year that you quit smoking: Raynaud s phenomenon smoke pipes or cigars Thyroid disease chew tobacco or dip snuff (circle which one) Deforming arthritis Osteoporosis currently drink alcohol Gout average number of drinks per day Pseudogout (CPPD disease) 1 drink= one beer, one glass of wine, Childhood arthritis or one shot of liquor Cancer previously was a drinker of alcohol What types? average number of drinks per day drink moonshine Blood clots tattoos Where did they occur? year first tattoo was placed currently working Miscarriages Brief job description: How far along was the pregnancy? Heart attack younger than 50 Stroke younger than 50 Married Ankylosing spondylitis Divorced Crohn s disease or ulcerative Single colitis psoriasis

4 Medication List Patient Name: Patient MRN: Date: Instructions: Please check any problems that have ever affected you. Medications Not allergic or intolerant to any medications Allergic or intolerant to the following medications (please list): List current prescribed medications: MEDICATION DOSE FREQUENCY (number of times taken per day) 1. _ 2. _ 3. _ 4. _ 5. _ 6. _ 7. _ 8. _ 9. _ 10. _ 11. _ 12. _ 13. _ 14. _ 15. _ 16. _ 17. _ 18. _ 19. _ 20. _ List current supplements and over-the-counter medications with dose and frequency taken per day (examples include calcium, ibuprofen, ginko, Tylenol): MEDICATION DOSE FREQUENCY

5 Review of Systems New Patient Patient Name: Patient MRN: Date: Instructions: Please check any problems that have ever affected you. Constitutional Gastrointestinal Integumentary Weight loss Nausea Rash amount pounds Vomiting Itching Weight gain vomiting blood Hives amount pounds Abdominal pain skin tightness Fever Diarrhea change in skin coloration highest recorded F Constipation swelling in the legs Fatigue Blood in days end Night sweats Black, tar-like stools all the time Chills Heartburn fingertips turn white or Change in appetite Trouble swallowing blue with cold or stress increased choking on solids decreased choking on liquids Neurological system food gets stuck after swallow headaches Head, eyes, ears, nose, mouth, throat changed? hair loss Genitourinary system fainting mucous membrane ulcers pain during urination muscle weakness mouth ulcers blood in urine difficulty walking nose ulcers (nside the nose) frothy or foamy urine tingling or numbness vaginal or penile ulcers increased frequency of urination stroke or mini-stroke vision changes night-time urination seizure redness in the eyes How often? times per night memory loss pain in the eyes vaginal or penile discharge confusion cataracts sexually transmitted disease tremor dry eyes gonorrhea twitches or movements dry mouth Chlamydia loss of coordination swollen glands in the head or neck dark-colored or tea-colored urine hoarseness in the voice For women: Hematological nosebleeds change in menstruation bleeding bleeding from the gums missed periods bruising hearing loss bleeding between periods new blood clot ringing in the ears heavy menstrual bleeding new anemia dizziness bleeding after menopause swollen lymph nodes lightheadedness pregnant tender? room spins around new miscarriage blood transfusion For men: Cardiovascular system erectile dysfunction Psychiatric chest pain morning erections depression/ sad mood palpitations prostate problems anxiety heart mumur excessive worry high blood pressure Musculoskeletal system heart disease Joint pain Endocrine heart attack List joints affected: new diabetes diagnosis stress test, heart surgery, or angioplasty new thyroid disease Raynaud s phenomenon finger ulcers/sores If so, how many? Allergic/immunologic toe ulcers/sores If so, how many? Morning stiffness in the joints infections How long: sneezing Respiratory minutes runny nose Shortness of breath hours itchy, watery eyes with activity at rest during sleep Joint swelling Cough List joints affected: Other productive of phlegm? What color? kidney stones coughing up blood thyroid disease occurs at night when sleeping diabetes Pleurisy (chest pain when taking a breath) fractures If so, where? Wheezing

6 AMERICAN COLLEGE OF RHEUMATOLOGY Patient Assessment Considering all the ways in which illness and health conditions may affect you at this time, please make a mark below to show how you are doing: Very Well Very Poorly How much pain have you had because of your condition over the past week? Place a mark on the line below to indicate how severe your pain has been: No Pain Pain as Bad as It Could Be Please answer the following questions, even if you feel that they may not be related to you at this time. Answer exactly as you think or feel there are no right or wrong answers. Check the one best answer for each question. Activity Level Right now, are you able to: Without any difficulty With some difficulty With much difficulty Unable to do 1. Dress yourself, including tying shoelaces and doing buttons? Get in and out of bed? Lift a full cup or glass to your mouth? Walk outdoors on flat ground? Wash and dry your entire body? Bend down to pick up clothing from the floor? Turn regular faucets on and off? Get in and out of a car, bus, train or airplane? Walk two miles? Participate in sports and games as you like? Get a good night s sleep? Deal with feelings of anxiety or being nervous? Deal with feelings of depression or feeling blue? For Office Use Only GL PN FN 1=0.33 2=0.67 3=1.0 4=1.33 5=1.67 6=2.0 7=2.33 8=2.67 9=3.0 10= = =4.0 13= = =5.0 16= = =6.0 19= = =7.0 22= = =8.0 25= = =9.0 28= = =10.0 Your Name Today s Date Time of Day Activity Level Index Scoring: For FN (questions 1-10) add total points and convert using scale on right. For PS (questions 11-13), add total points. Instructions for Office Staff Visual Analog Scales: measure with metric ruler. Line is exactly 10 cm long. Scores should be recorded in cm.mm format. Adapted from Pincus T, Swearingen C, Wolfe F. Toward a Multidimensional Health Assessment Questionnaire. Arthritis Rheum 1999; 42: Patient Assessment Form 1999, Health Report Services. Used with permission.