Medical Information Form
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1 Medical Information Form JILANNE ROSE, MSN, ANP-C CLINICAL DIRECTOR JOEL R. RAINWATER, MD MEDICAL DIRECTOR Name: Date of Birth: Age: Occupation: Ethnicity: Primary Care Physician: Pharmacy: Referring Physician: Medication Allergies: No Known Allergies / Sulfa Penicillin Latex Adhesive/Tape Acetaminophen Current Medications: Other(s): Name Dose (mg/units/etc.) Frequency (daily/every 4 hrs/etc.) Family History (Check all that apply): Mother Father Grandparents Vein Disease/Varicose Veins Premature Coronary Disease (under the age of 55) Blood Clots/ Phlebitis Arterial Disease/ Blockages in the neck or leg arteries Social History: Do you smoke tobacco? Yes / No If yes, how long have you smoked? How much do you typically smoke in one day? Do you drink alcohol? Yes / No If yes, how often?
2 Medical History (Circle all that apply): Migraines/Headaches Stroke/TIA Carotid Artery Disease/Blockage COPD/Emphysema Asthma Bronchitis/Pneumonia High Blood Pressure Coronary Artery Disease Irregular Heart Beat/A-fib High Cholesterol Diabetes Thyroid Insufficiency GERD/Stomach Ulcer Hernia Kidney Disease/Insufficiency/Failure Hepatitis B/C Blood Disorder Arthritis Lymphedema Open Sores/Wounds Recurrent skin/soft tissue infections Cancer (type and treatment): Any other health condition, not mentioned above: Surgical History: Have you experienced any of the following symptoms within the past year? (Please circle all that apply): Syncope Seizures Tremors Changes in memory or mentation Vertigo Visual changes Hearing loss Ringing in the ears Sinus trouble Shortness of breath Wheezing Chest pain Palpitations Abdominal pain Nausea/Vomiting Blood in the urine Blood in stool Diarrhea Constipation Skin pigment changes Skin rash/itching Bruising easily Joint pain Muscle pain How long have your legs bothered you? days weeks months years What time of the day do your leg symptoms bother you the most? Standing/sitting for long periods of time At the end of the day At night In the morning Walking more than 75 feet At any time of the day Never How much leg pain/discomfort have you had in the past four weeks? None Very Mild Mild Moderate Severe More than Severe During the last four weeks to what extent has your leg discomfort interfered with your normal social activities? Not at all Slightly Moderately Significantly Severely (needed to cancel/reschedule events)
3 Does the discomfort in your legs affect your daily activities at work/home (housework, yardwork, cleaning)? Not at all Slightly Moderately Significantly Severely (Unable to complete daily tasks) Are leg symptoms made worse by heat? YES NO In the past 4 weeks have you taken painkilling tablets due to leg pain? YES NO During the past 4 weeks, how much trouble have you had carrying out the actions and activities listed below because of your leg problems? For each statement in the tablet below, indicate how much trouble you have had by checking the box that applies to you. a. Remaining standing for a long time b. Doing certain jobs at home (e.g. standing and moving around in the kitchen, carrying a child in your arms, cleaning the floor, ironing, or dusting furniture, house projects ) No trouble Slight Moderate Considerable Could not trouble trouble trouble do it c. Sitting for long periods of time d. Going out for the evening, to a wedding, a party, a cocktail party In the past four weeks have you: Felt concerned about the appearance of your legs? Not at all Sometimes All the time Felt like a burden to family/friends? Not at all Sometimes All the time Been worried about the appearance of your legs? Not at all Sometimes All the time Been worried about bumping or scraping your legs? Not at all Sometimes All the time In your own words, what is the reason you are seeking treatment today? (i.e., pain behind right knee, heaviness in both legs, varicose veins for 20 years and my legs hurt etc.)
4 Leg problems can also affect your spirits. How closely do the following statements correspond to how you have felt during the past 4 weeks? For each statement in the tablet below, indicate how much trouble you have had by checking the box that applies to you. Not at all A little Moderately A lot Completely a. I felt nervous/tense b. I got tired quickly c. I felt I was a burden d. I always had to be cautious e. I felt embarrassed about my legs f. I got irritated easily g. I felt as if I was handicapped h. I found it hard to get going in the morning i. I did not feel like going out In the past 3 months, have you experienced any of the following symptoms in your legs? Heaviness/Fullness Never A few times a month About once a week Several Times a Week Daily Aching Never A few times a month About once a week Several Times a Week Daily Fatigue Never A few times a month About once a week Several Times a Week Daily Swelling Never A few times a month About once a week Several Times a Week Daily Cramping Never A few times a month About once a week Several Times a Week Daily Restless Legs Never A few times a month About once a week Several Times a Week Daily Itching Never A few times a month About once a week Several Times a Week Daily Burning/Numbness Never A few times a month About once a week Several Times a Week Daily Pain Never A few times a month About once a week Several Times a Week Daily Ruptured varicosities Never A few times a month About once a week Several Times a Week Daily Ulcers/Wounds Never A few times a month About once a week Several Times a Week Daily Bruising Easily Never A few times a month About once a week Several Times a Week Daily Pelvic Symptoms Never A few times a month About once a week Several Times a Week Daily
5 During the past 4 weeks, to what extent did you feel bothered/limited in your work or your other daily activities because of your leg problems? Not bothered/limited A little bothered/limited Moderately bothered/limited Very bothered/limited Extremely bothered/limited During the past 4 weeks, did you sleep badly because of your leg problems, and how often? Seldom Fairly Often Very often Every night Right leg left leg None at all In the last 2 weeks for how many days did your veins cause you pain or ache? Between 1 and 5 days Between 6 and 10 days For more than 10 days Right leg Left leg None at all During the past 2 weeks, on how many days did you take painkillers or antiinflammatories for your leg symptoms? Between 1 and 5 days Between 6 and 10 days For more than 10 days Right leg Left leg None at all In the last 2 weeks, how much ankle swelling have you had? Between 1 and 5 days Between 6 and 10 days For more than 10 days Does one leg bother you more than the other? no; both legs are equal yes; Right Left Have you done leg exercises? YES NO Have you done leg elevation? YES NO How long have you worn compression stockings? No Yes If yes; how long?
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Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
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Intake form Name Today s Date Date of Birth Address City Phone Postal Code Email Primary Health Care Provider Emergency Contact Phone Note: By providing your email address you are giving us consent to
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