PATIENT INFORMATION SHEET
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- Ethelbert Bradley
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1 PATIENT INFORMATION SHEET (PLEASE PRINT ALL INFORMATION) LAST NAME FIRST NAME MIDDLE INIT WHAT FIRST NAME DO YOU PREFER? RACE MARITAL STATUS: S M D W SS # DATE OF BIRTH AGE: ADDRESS SEX M F CITY STATE ZIP HOME # ( ) CELL # ( ) EMPLOYER WORK # ( ) SPOUSE S NAME EMPLOYER WORK # ( ) LEGAL GARDIAN PRIMARY CARE PHYSICIAN PHONE # REFERRING PHYSICIAN PHONE # PHARMACY PHONE # MAIL OFF PHARMANCY PHONE # PRIMARY INSURANCE: FAX # NAME GROUP NAME ADDRESS POLICY # CITY STATE ZIP GROUP # PHONE # ( ) FAX # ( ) POLICY HOLDER DATE OF BIRTH RELATIONSHIP EMPLOYER ADDRESS SECONDARY INSURANCE: NAME GROUP NAME ADDRESS POLICY # CITY STATE ZIP GROUP# POLICY HOLDER DATE OF BIRTH CONTACT IN CASE OF EMERGENCY: NAME HOME # RELATIONSHIP WORK # I HEREBY AUTHORIZE ANY PHYSICIAN, HOSPITAL, OR MEDICAL CARE FACILITY TO PROVIDE OR RECEIVE MY MEDICAL INFORMATION IN THE COURSE OF MY TREATMENT BY DR. HAKIM OR DR. FLAGG. FUTHERMORE, I AUTHORIZE THE REALEASE OF ALL MY MEDICAL RECORDS TO MY INSURANCE COMPANY AND PAYMENT OF BENEFITS TO ARTHRITIS & RHEUMATIC DISEASES, P.C. DATE PATIENT S SIGNATURE:
2 Patient Name Nickname Age: Chart # Referred By: PCP: PATIENT CURRENT MEDICAL HISTORY FORM REASON FOR CONSULT: (please circle) Back Hip Shoulder Neck Elbow Hand Finger Knee Ankle Feet Rheumatoid Arthritis Gout Lupus Osteoarthritis Osteoporosis Tendinitis Bursitis Raynauds Scleroderma Joint Elevated Lab Polymyalgia Rheumatica Sjogrens Syndrome Rash Ankylosing Spondylitis Carpal Tunnel PolyArthralgias Sacroiliitis CHIEF COMPLAINT: Date Symptom Symptom Type Intensity Began Frequency Of Frequency Of Symptoms Constant Intermittent Occasional Rare Constant Intermittent Occasional Rare Constant Intermittent Occasional Rare Recurrent Recurrent Recurrent Please thadil 1111 the IocalioIlt 01 your piiin over tile peat WMk on the bodyfigulm and hinda. tt-." How did symptom start and progress? What brings symptoms onl or what do you have difficulty with?? (please circle) Walking Climbing Stair Descending Stairs Sitting Down Getting Up from chair Grasping small objects Reaching behind back Reaching behind head Dressing yourself Bathing Going to sleep Staying asleep Obtaining restful sleep Morning Stiffness Working Engaging in leisure time activities Participating in Sports Sexual activity Treatments Used: (please circle) Physical Therapy Chiropractor Injections Massage Therapy Surgery Othet: SECONDARY COMPLAINT: Date Symptom Symptom Type Intensity Began Frequency Of Frequency Of Symptom Constant Constant Constant Intermittent Intermittent Intermittent Occasional Occasional Occasional Rare Rare Rare Recurrent Recurrent Recurrent p..,:;t'(t $hade all the locations of your pain 0\1' l the past week on tj\., r:odyfigureoand hands. CaampIe: How did symptom start and progress?
3 PAST MEDICAL HISTORY DO YOU NOW OR HAVE YOU EVER HAD? (Please Circle and describe) Cancer Goiter Cataracts Nervous Breakdown Bad Headaches Kidney Disease Anemia Emphysema Heart Problems Leukemia Diabetes Stomach Ulcers Jaundice Pneumonia HIV/AIDS Glaucoma Asthma Stroke Epilepsy Rheumatic Fever Colitis Psoriasis High Blood Pressure Tuberculosis Thyroid Disease Osteoporosis Osteopenia Medical Problems: Other Significant Illness: SURGERIES : TYPE DATE PHYSICIAN RESPONSE Any previous fractures? No Yes Age: Describe: Any serious injuries? N o Yes Describe: Natural or Alternative Therapies: Chiropractic Care No Yes Massage No Yes Acupuncture No Yes Supplements/Vitamins: Over the counter preparations: TESTING: Date of Last Exam & Location Chest X-ray Eye Exam TB Skin Test MRI EKG X-Rays EMG Lab Work Dexa Scan ESI IMMUNIZATIONS: Date of Last Exam Influenza Pneumoccocal Tetanus Shingles
4 SOCIAL HISTORY EDUCATION (circle highest level attended): Grade School College Graduate Degree WORK HISTORY Occupation (s) # of Years Please Circle Ones That Apply Mental Work: Light Moderate Heavy Hours per Day Physical Work: Light Moderate Heavy Hours per Day Exercise: Light Moderate Heavy Hours per Wk Retired or Disabled (Please Circle) Age Do you exercise regularly? Yes No Type: Amount Per Wk Do you get enough sleep at night? Yes No Do you wake up feeling rested? Yes No Marital Status: Single Not Married Married Divorced Widowed Spouse/Significant Other: Alive/Age Deceased/Age Illness Please Check All That Apply Alcohol (per week): Never Beers Liquor Wine # of Years Has anyone ever told you to cut down on your drinking? Yes No Tobacco (per day): Never Current D/C Type Quantity Number of Years Caffeine: Cups per Day # of Years Aspirin: Qty per Day # of Years Tylenol Qty per Day # of Years MISCELLANEOUS DRUGS Marijuana Never Current D/C Cocaine Never Current D/C Pills Never Current D/C Please Circle Ones That Apply Low Sodium Diet Special Diets Antacids Saccharin Vitamins Low Fat Diet Sleeping Pills Diet Pills Laxatives NutraSweet Low Cholesterol Diet Vegetarian Diet
5 FAMILY HISTORY RHEUMATOLOGIC FAMILY HISTORY Have you or a blood relative had any of the following? Disease Yourself Relative/Relationship (Please Check) (Please List) Arthritis Osteoarthritis Gout Lupus or SLE Rheumatoid Arthritis Ankylosing Spondylitis Osteoporosis Childhood Arthritis # OF BROTHERS & SISTERS # LIVING # DECEASED # OF CHILDREN # LIVING # DECEASED HEALTH OF CHILDREN: (Please Circle) FATHER AGE HEALTH STATUS: Poor Fair Guarded Stable Good Excellent AGE at DEATH REASON ANY ILLNESSES? MOTHER AGE HEALTH STATUS: Poor Fair Guarded Stable Good Excellent AGE at DEATH REASON ANY ILLNESSES? DO YOU HAVE ANY BLOOD RELATIVE WHO HAS OR HAD? (Please Circle and Specify) Cancer Leukemia Stroke Colitis Heart Disease High Blood Pressure Alcoholism Bleeding Tendency Rheumatic Fever Epilepsy Asthma Psoriasis Tuberculosis Thyroids DS Diabetes Multiple Sclerosis
6 PLEASE PRINT ALL INFORMATION CURRENT MEDICATION/ ALLERGIES Patient Name Chart # ALLERGIES Allergies Reactions CURRENT MEDICATIONS Name of Drug Dosage Medication Date Prescribing Amount Frequency Prescribed Physician DISCONTINUED MEDICATIONS Name of Drug Date Discontinued Reason
7 First Name: Middle: Last Name: REVIEW OF SYMPTOMS Check Only The Ones You NOW Have Or Have Had Recently GENERAL Weakness Fatigue Fever Malaise Chills Night Sweats Fainting Dizziness Weight Loss Weight Gain SKIN Color Changes Nail Changes Hair Changes Moles Rashes Itching Sores Dryness Redness Easy Bruising Sun Sensitive HEAD Headaches Injuries Bumps EYES Contacts Cataracts Blurred Vision Glaucoma Redness Itching Dryness Tearing Swelling Burning EARS Hard of Hearing Deafness Ringing Discharge Earache Itching Loss of Balance Dizziness Room Spins NOSE Decreased Smell Bleeding Discharge Runny Nose Deviated Septum Sinus Congestion MOUTH Bleeding Gums Sores Dental Problem Bad Breath Loss of Taste Dryness Ulcers Blisters BLOOD Anemia Easy Bruising Broken Blood Vessels Prolonged Bleeding Swollen Nodes ful Nodes Red Dots/Spots PSYCHIATRIC Depression Insomnia Irritability Insecurity/Timid Indecisiveness Hyperventilation Anxiousness/Stress Worrying Obsessiveness Hallucinations Alcohol Abuse Drug Use Mania/Depression Panic Attacks THROAT Sore Throat Hoarseness Hard to Swallow Recurrent Infections White Spots Bad Tonsils GASTROINTESTINAL Abdominal Nausea Vomiting Bloatedness Belching Heartburn Indigestion Irregular Bowels Constipation Diarrhea Rectal Bleeding Gas Hemorrhoids Hernias Poor Appetite Food Intolerance Bloody Stools Black Tarry Stools Excessive Appetite ENDOCRINE Hoarseness Heat Intolerance Cold Intolerance Breast Changes Loss Of Hair Extreme Thirst Voice Changes Excessive Hair Hypoglycemia Diabetes NECK Enlargement Stiffness Soreness Lumps Masses BREASTS Discharge Nodules /Tenderness Changes Skin Bloatedness Masses Bleeding GENITOURINARY Urgency Incontinence Straining Flank Frequency Stones Burning Bloody Bed Wetting Small Stream Urethral Discharge Cloudy Urine Unusual Color Night Hesitancy MUSCULOSKELETAL List Joints Affected in Weakness the last 6 months. Cramps Twitching Joint Stiffness Joint Joint Swelling Joint Deformities Injuries Curvature of Spine Back Hot Joint Morning stiffness lasting how long? minutes hours LUNGS Cough Phlegm Coughed Blood Shortness of Breath Wheezing in Lungs Chest Congestion Inhalant Exposure GYNECOLOGICAL Post Menopausal Vaginal Discharge Labial Sores Hot Flashes Mood Swings Night Sweats Sexual Difficulty Date of Last Menses / / Last Mammogram / / Age at 1 sr. Period Age at Menopause VITALS SIGNS Height: Weight: Resp: Temp: Sitting: Standing: HEART Murmur Palpitations Rapid Heartbeat Swollen Extremities Tightness/Pressure Chest s Varicose Veins Blood Clots Blue Extremities NEUROLOGICAL Seizures Vertigo Hand Trembling Loss of Sensation Incoordination Weak Grip Paralysis Slurred Speech Loss of Memory Tingling/Burning/ Numbing Lack of Concentration Muscle Spasm Disorientation Gait Shuffling B.P Pulse Extremity Supine:
8 PATIENT NAME PAST MEDICATION HISTORY SHEET Please review this list of Arthritis medications. As accurately as possible, try to remember which medications you have taken and mark how they helped you. PAIN RELIEVERS Helped: (A lot) (Some) (Not At All) Acetaminophen (Tylenol) Codeine (Vicodin/ Hydrocoden, Tylenol #3) Propoxyphene (Darvon/Darvocet) Oxycodine/Percocet Oxycontin (Oxy IR) Ultram Durgesic/Fentanyl DISEASE MODIFYING ANTIRHEUMATICS Auranofin, Gold Pills (Ridura) Gold Shots (Myochrysine or Solganol) Hydroxychloroquine (Plaquinel) Penicillamine (Cuprimine or Depen) Methotrexate (Rheumatrex) Azathioprine (Imuran) Sulfasalazine (Azulfidine) Quinacrine (Atabrine) Cyclophosphamide (Cytoxan) Cyclosporine A (Sandimmune or Neoral) Etanercept (Enbrel) Infiximab (Remicade) Humira Orencia Rituximab Arava CellCept NON-STERIODAL ANTI-INFLAMMATORY (NSAIDS) Ansaid (flubiprofen) Daypro (oxaprozin) Meclomen (meclofenamate) Tolectin (tolmetin) Arthrotec (diclofenac) Dolobid (diflunisal) Motrin/Rufen(ibuprofen) Trilisate (choline magnesium) Feldene (piroxiacam) Mobic (meloxican) Please complete other side August 2012
9 PAST MEDICATION HISTORY SHEET (Page 2) Please review this list of Arthritis medications. As accurately as possible, try to remember which medications you have taken and mark how they helped you. Helped: (A lot) (Some) (Not At All) Celebrex (celecoxib) Indocin (indomethacin) Naprosyn (naproxen) Voltaren (diclofenac) Clinoril (sulindac) Lodine (etodolac) Oruvail (ketoprofen) GOUT MEDICATIONS Probenecid (benemid) Colchicine Allopurinol (zyloprim/lopurin) OSTEOPOROSIS MEDICATIONS Estrogen (premarin, ect) Alendronate (fosomax) Etidronate (didronel) Raloxifene (evista) Boniva IV or Oral Calcitonin Injection or Nasal (miacalcin,calcimar) Residronate (actonel) Forteo Reclast/Zometa Prolia OTHER MEDICATIONS Aramotase Inhibitor Tamoxifen (nolvadex) Tiludronate (skelid) Cortisone Prednisone Hyalgan/Synvisc/ Supartz Injections Herbal or Nutritional Supplements List of Herbs or Supplements: / Have you participated in any clinical trials for new medications? Yes No If yes, list: August 2012
NEW PATIENT INFORMATION
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Greensboro Medical Associates, PA 1511 Westover Terrace Suite 201 Greensboro, NC Date of first appointment:
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ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
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