OU Children s Physicians Pediatric Arthritis Center
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- Anis Blair
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1 Please complete the following questionnaire for your child: Patient Name: Birth Date: Parent/Caretaker Name: Primary Care Physician (Full Name, City, & State) Mother s Occupation: Fathers Occupation: Name of School: Teacher/Contact: Grade/Year of study: I. 1. Reason for your visit: 2. How long have you had this problem? II. 1. Do you have fever? Yes / No a. If yes, what is the actual temperature? b. How long does the fever last? 2. Do you have shaking chills with the fever? Yes/No 3. How many times have your symptoms occurred? per day in the past weeks in the past months 4. Do you have joint stiffness? Yes / No a. In the mornings? Yes / No After exercise or activity? Yes / No b. How long does the stiffness last? (minutes/hours) c. What do you do for the stiffness? 5. Do your joints become: Visibly swollen? Yes / No Warm? Yes / No Reddened? Yes / No Tender or painful to move? Yes / No a. If so, which joints are affected? b. How long (hours, days, or weeks) do the joint changes last? c. Do the joint changes persist in the same joint(s), or do the changes move around from joint to joint? 6. Do you awaken at night with the pain? Yes / No 7. Do you have joint pain especially after exercise or activity? Yes / No 8. What do you do for the joint problems? 9. Do you have a lot of fatigue? Yes / No a. How long does the fatigue last? b. How much sleep do you get each night? hours c. Do you also need daytime sleep due to fatigue? Yes / No 10. Have you lost weight? Yes / No If so, how much? 11. Do you miss school? Yes / No How many days in the last month(s)? 12. Are you able to keep up with the activities of your peers? Yes / No
2 Page 1 of When you have joint problems, fever, or excessive fatigue, do you also have any of the following symptoms? a. Body rash (location ) b. Facial rash c. Skin ulcers (location ) d. Easy bruising e. Chest pain f. Painful breathing g. Abdominal pain h. Bloody stools i. Pink or bloody urine j. Low back pain k. Heel pain l. Muscle weakness m. Muscle pain n. Eye problems (redness, blurred vision, or light sensitivity) o. Other: III. 1. What are your known medical problems? 2. What prior surgeries have you had (include circumcision, tonsillectomy, etc.)? 3. What medicines do you currently take? Please list the drug, dose, and frequency: 4. Are you allergic to any medicine? (Please list) 5. Have you ever been hospitalized? Yes / No a. Please list the dates and reason for hospitalization: 6. Are you up to date with your immunizations? Yes / No a. When was your last TB screening test? 7. Have you been traveling recently? Yes / No If so where? 8. Have you been in an area known to be inhabited by deer? Yes / No
3 Page 2 of 4 IV. 1. Do any family members have any of the following medical problems? If yes, please indicate the family member. a. Rheumatoid arthritis (adult onset) b. Childhood onset arthritis c. Lupus d. Immune deficiency (chronic infection) e. Colitis/Inflammatory bowel disease f. Ankylosing spondylitis g. Psoriasis h. Hemophilia or other bleeding disorder i. Knee pain j. Low back pain k. Heel pain l. Inflammation of the eye m. Diabetes n. Other autoimmune disease (thyroid, adrenal, liver) o. Cancer p. Multiple sclerosis q. Myasthenia gravis r. Growing pains s. Excessively mobile joints t. Rheumatic fever V. 1. Have you had any of the following occur with your main problem? a. Rash which occurs in sun-exposed areas of your body b. Skin tightening c. Skin discoloration d. Hair loss e. Headache f. Jaw pain g. Sudden paleness of the skin (fingers, hand, toes, earlobe, nose) with or without exposure to cold h. Dry eyes or mouth i. Mouth or nose ulcers j. Sore throat k. Persistent cough l. Coughing up blood m. Difficulty swallowing n. Nausea or vomiting o. Heartburn p. Constipation q. Diarrhea r. Genital ulcers s. Genital discharge t. Seizures u. Tingling, burning or numbness of hands, face, or feet v. Psychological disturbances/personality changes
4 Page 3 of 4 VI. 1. Do you have a known exposure to any environmental pollutants or hazards? 2. Do you perform any physically repetitive tasks at school, home, or work? Examples would include playing video games, prolonged typing, etc. 3. Please list your brothers and sisters full names, and please note if they have any medical problems. 4. I participate in individual and/or team sports: 5. I am unable to do the following activities that I would normally do: 6. Please list any adaptive equipment you currently use: 7. Are you currently using any splints or orthotic devices? If so, please indicate which items you use: 8. Do you do any physical therapy? If so, please list how often this is performed: 9. I have also seen the following specialist doctors for this problem:
5 Page 4 of 4
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1. Have you ever had or now have: 2. Have you ever had or now have: Yes No Please Check each item no blanks CARDIOVASCULAR Yes No Often Seldom 1. Chronic or frequent colds 1. Shortness of breath with normal
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
Initial Patient Intake Form
Initial Patient Intake Form Patient Registration Today s Date Patient Name (last) (first) (middle) Address (city) (state) (zip) Date of birth (mm/dd/yyyy) SSN # Current Gender Identity: Male Female Transgender
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
Name: Sex: Male Female. Date of Birth: Occupation: Is this an accident or work related injury?
Name: Sex: Male Female Date of Birth: Occupation: Is this a 2 nd opinion? Yes No Is this an accident or work related injury? Please list: Family MD: Referring MD: Address: Address: Phone: Phone: Fax: Fax: