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1 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 Separated Widowed Partnered/significant other Name of your referring Physician: Name of your primary care physician: Describe briefly your present symptoms: When did your symptoms start? What diagnosis have you been given, if any? Please list the names of other practitioners you have seen for this problem: Previous treatment for this problem (include physical therapy, surgery, and injections; medications to be listed later): 1
2 RHEUMATOLOIC (ARTHRITIS) HISTORY At any time have you or a blood relative had any of the following? (check if yes ) Yourself Relative Arthritis (type unknown) Osteoarthritis Rheumatoid arthritis out Lupus or SLE Ankylosing spondylitis Childhood arthritis Sjogren s syndrome Osteoporosis Psoriasis/psoriatic arthritis PAST MEDICAL HISTORY Do you now or have you ever had: (check if yes ) Diabetes Heart murmur High blood pressure Pneumonia High cholesterol Pulmonary embolism Hypothyroidism Asthma oiter Emphysema Cancer (type) Stroke Leukemia Epilepsy (seizures) Psoriasis Cataracts Angina Kidney disease Heart problems Kidney stones Name/relationship Crohn s disease Colitis Anemia Jaundice Hepatitis Stomach or peptic ulcer Rheumatic fever Tuberculosis HIV/AIDS Other significant illnesses (please list): Previous Operations Type Immunization History Flu Shot Pneumonia Shot Zoster/Shingle Shot Any previous fractures? No Yes Year Reason Describe Any other serious injuries? No Yes Describe Do you smoke? Yes No In the past - How long ago? Do you drink alcohol? No Yes : Usual drink: How much: Has anyone ever told you to cut down on your drinking? Yes No Do you use drugs for reasons that are not medical? No Yes If yes, please list: Do you get enough sleep at night? Yes No Do you wake up feeling rested? Yes No 2
3 MEDICATIONS and SUPPLEMENTS Drug allergies: No Yes To what? Please list any medications that you are now taking. Include non-prescription medications, such as aspirin, vitamins, glucosamine, laxatives, calcium, etc. Name of drug Dose (include strength and number of pills per day) PERSONAL HISTORY What is your highest educational level? High school Some college courses College graduate Advanced degree What is your current or past occupation? Are you currently working? : Yes No If yes, hours/week Do you receive disability or SSI? Yes No If not, are you retired disabled sick leave? If yes, for what disability? What date did this disability begin? With whom do you currently live? How much exercise do you get each week? FAMILY HISTORY IF LIVIN Age Health Father Mother What kind of exercise? Age at death IF DECEASED Cause Number of siblings: Number living Number of children Number living List ages of each Health of children: 3
4 SYSTEMS REVIEW Date of last eye exam Date of last chest x-ray Date of last bone density test Result of last TB (PPD) test: Never done Negative Positive ENERAL Recent weight gain; how much Recent weight loss: how much Fatigue Weakness Fever Night sweats MUSCLE/JOINTS/BONES Morning stiffness Lasting how long Minutes Hours Joint pain Muscle weakness Joint swelling List joints affected in the last 6 months EARS Ringing in ears Loss of hearing EYES Pain Redness Loss of vision Double or blurred vision Dryness Feels like something in eye MOUTH Sore tongue Bleeding gums Sores in mouth Loss of taste Dryness Recent increase in tooth cavities NOSE Nosebleeds Loss of smell Date test performed: THROAT Frequent sore throats Hoarseness Difficulty in swallowing Pain in jaw while chewing NECK Swollen glands Tender glands HEART AND LUNS Pain in chest Irregular heart beat Sudden changes in heart beat Shortness of breath Difficulty in breathing at night Swollen legs or feet Cough Coughing of blood Wheezing STOMACH AND INTESTINES Nausea Heartburn Stomach pain relieved by food Vomiting of blood/ coffee grounds Yellow jaundice Increasing constipation Persistent diarrhea Blood in stools Black stools KIDNEY/URINE/BLADDER Difficult urination Pain or burning on urination Blood in urine Cloudy, smoky urine Pus in urine Discharge from penis/vagina Frequent urination etting up at night to pass urine Vaginal dryness Rash/ulcers Sexual difficulties Prostate trouble 4 BLOOD Anemia Bleeding tendency SKIN Easy bruising Redness Rash Hives Sun sensitive Skin tightness Nodules/bumps Hair loss Color changes of hands or feet in the cold (Raynaud s) NERVOUS SYSTEM Headaches Dizziness Fainting or loss of consciousness Numbness or tingling in hands/feet Memory loss Muscle weakness PSYCHIATRIC Depression Excessive worries Difficulty falling asleep Difficulty staying asleep For women only: Age when periods began: Number of pregnancies: Number of miscarriages: Have you reached menopause? No Yes If yes, at what age: Date of last Pap smear: Date of last mammogram: If you are still having periods: Are they regular? Yes No How many days apart?
5 R Date: / / NAME: Last First M. I. Birthdate: / / routine assessment of patient index data The RAPID3 includes a subset of core variables found in the Multi-dimensional HAQ (MD-HAQ). Page 1 of the MD-HAQ, shown here, includes an assessment of physical function (section 1), a patient global assessment (PA) for pain (section 2), and a PA for global health (section 3). RAPID3 scores are quickly tallied by adding subsets of the MD-HAQ as follows: 1. please check the ONE best answer for your abilities at this time: 1. a-j FN (0-10): OVER THE LAST WEEK, were you able to: without ANY with SOME with MUCH UNABLE to do a. Dress yourself, including tying shoelaces and doing buttons? b. et 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. et in and out of a car, bus, train, or airplane? i. Walk two miles or three kilometers, if you wish? j. Participate in recreational activities and sports as you would like, if you wish? k. et a good night s sleep? l. Deal with feelings of anxiety or being nervous? m. Deal with feelings of depression or feeling blue? =0.3 2=0.7 3=1.0 4=1.3 5=1.7 6=2.0 7=2.3 8=2.7 9=3.0 10=3.3 11=3.7 12=4.0 13=4.3 14=4.7 15=5.0 16=5.3 17=5.7 18=6.0 19=6.3 20=6.7 21=7.0 22=7.3 23=7.7 24=8.0 25=8.3 26=8.7 27=9.0 28=9.3 29=9.7 30=10 2. PN (0-10): 3. PTE (0-10): RAPID3 (0-30) 2. how much pain have you had because of your condition OVER THE PAST WEEK? Please indicate below how severe your pain has been: NO PAIN 0 PAIN AS BAD AS IT COULD BE considering all the ways in which illness and health conditions may affect you at this time, please indicate below how you are doing: VERY WELL 0 VERY POORLY
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