ANDRES PEISAJOVICH MD 3820 MASTHEAD ST NE ALBUQUERQUE, NM PH: FAX:
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1 ANDRES PEISAJOVICH MD 3820 MASTHEAD ST NE ALBUQUERQUE, NM PH: FAX: Please arrive 30 minutes prior to your appointment. Bring this completed packet with you. Completing the enclosed packet before your visit will give your Rheumatologist important information about you. To better assist us Dr Peisajovich request that you bring to your appointment any office notes, labs and radiology reports pertaining to this visit. If you don t have any of those reports, please obtain them from your referring physician, and bring them to your visit to avoid any delay in this appointment.
2 Rheumatology New Patient Packet Date of appointment: / / Time of appointment: : Name: Birth date: / / Marital Never Status Married Married Divorced Separated Widowed Partnered Occupation: Referred by: Previous Rheumatologist: Have you had any orthopedic surgeries? No Yes, Briefly describe your current symptoms: Date symptoms began: / / Diagnosis: Previous treatment for this problem (include physical therapy, surgery and injections; medications to be listed later): Please list all names of other practitioners or rheumatologists you have seen for this problem: How much pain have you had because of your condition OVER THE PAST WEEK? Considering all the ways in which illness and health conditions may affect you at this time, please indicate below how you are doing:
3 Past Medical History: Please check or list any medical conditions Back pain Lupus High Cholesterol Depression/Anxiety Fibromyalgia Gout Heart Disease Hypertension Osteoarthritis Osteoporosis/Osteopenia Psoriasis Rheumatoid Arthritis Thyroid Disease Other: Activities of Daily living: Please check the ONE best answer for your abilities at this time Without Any Difficulty With Some Difficulty With Much Difficulty Unable a. Dress yourself, including tying shoelaces and doing buttons b. Get in and out of bed c. Lift a full cup or glass to your mouth d. Walk outdoors on flat ground e. Wash and dry your entire body f. Bend down to pick up clothing from the floor g. Turn regular faucets on and off h. Get in and out of a car, bus, train, or airplane I. Walk two miles or three kilometers, if you wish? j. a. Participate in recreational activities and sports as you would like, If you wish?
4 Past Surgical History: Please list all surgeries Date Surgery Date Surgery Medications: Medication Dose Frequency Drug Allergies: Medication Reaction Medication Reaction Family History: Disease Relationship Disease Relationship Rheumatoid arthritis Osteoarthritis Lupus Gout Cancer Diabetes Heart High Cholesterol
5 Osteoporosis Psoriasis/Psoriatic arthritis Rashes/Skin Problems Seizures Thyroid Disease Hypertension Migraines Asthma Stroke Other: Review of Systems: Constitution Chills Fatigue Fever MS Joint Pain Back Pain Joint Swelling Muscle Pain HEET Mouth Sores Trouble Swallowing Skin Color Change Rash Eyes Eye Redness Visual Problems Neurological Numbness Weakness Respiratory Chest Tightness Shortness of Breath Cough Cardiovascular Chest Pain Leg Swelling Hematologic Adenopathy (enlarged glands) Bruises/ Bleeds easily Psychiatric Sleep Disturbance Depression/Anxiety GI Abdominal Pain Blood in Stool GU Trouble Urinating Blood in Urine Date of last eye exam: / / Date of last Tuberculosis Test: / / Date of last bone densitometry: / / Date of last chest x-ray: / / Tobacco Use: Current Past Packs per Day Quit date: / / Alcohol Use: Type Drinks per week Recreational Drugs: Marijuana Cocaine Heroin IV Drugs Other
6 OB History Number of Pregnancies Number of Full Term Complications: Number of Miscarriages Number of Preterm Please shade all the locations of your pain over the past week on the body figures and hands:
LIST ALL CURRENT MEDICATIONS BELOW INCLUDING INJECTIONS/INFUSION MEDICINES MEDS) Name of Medication Dose How often taken
Please take a moment to fill out the following forms front and back: Pharmacy Information: (Include the Name, Address and Phone Number of the Pharmacy) Preferred Local: Preferred Mail Order/Specialty:
Physician initials. Date: / / Birthdate: / / Age: Sex: F M
Arthritis and Rheumatology Clinical Center of Northern Virginia R RHEUMATOLOY PATIENT HISTORY FORM Date: / / NAME: Last First M. I. Birthdate: / / Age: Sex: F M Marital status: Never married Married Divorced
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The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
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BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D.
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D. PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC Name: Age: Sex: Male Female Occupation: Job description: Date: PLEASE ANSWER THE FOLLOWING QUESTIONS: Major
PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT
Date: Bariatric Services Digestive Health Center Oregon Health & Science University 3303 SW Bond Avenue CHH6D Portland, OR. 97239 Phone: (503) 494-1983 Fax: (503) 418-3683 Email: w8reduce@ohsu.edu www.ohsuhealth.com/surgicalweightreduction
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
History of Present Problem
Patient Name: Date: If you are not the patient: Guardian name: Relationship to Patient: Height: Ft In Weight: lbs Age: Birth Date: Dominant Hand: Right Left Shoe Size: Primary Care Physician: Specialists: