PATIENT MEDICAL HISTORY PATIENT INFORMATION

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Susanna Gibson
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PATIENT MEDICAL HISTORY PATIENT INFORMATION Name: Referred here by: Self Family Friend Doctor Other Health Professional If Doctor, please give name & address: List doctors seen in the last 24 months:

1 PATIENT MEDICAL HISTORY PATIENT INFORMATION Name: Referred here by: Self Family Friend Doctor Other Health Professional If Doctor, please give name & address: List doctors seen in the last 24 months: Relative(s) to get in touch with in case of emergency: Name: Address: Phone Number: Name: Address: Phone Number: HISTORY OF PRESENT ILLNESS What symptoms are you having which prompted you to seek a consultation with the SIMED Arthritis Center? Please list previous treatment for this problem (include physical therapy, surgery and/or injections (medications to be listed later)). PAST MEDICAL HISTORY Do you have any allergies to or problems with medications? (If so, please list the medicine, the type of reaction (rash, nausea, low blood pressure, trouble breathing, etc ) and when the episode occurred). Do you have any known food allergies? (If so, please list the foods and the reaction noted). Tina Brar, MD Meghavi Kosboth, DO T. Mark Lloyd, MD Miguel Rodriguez, MD Donald Scott, MD Michael Rozboril, MD P: F: Newberry Road, Suite 8, Gainesville, FL 32607

2 PAST MEDICAL HISTORY (CONT D) Have you ever had any surgical procedure(s) performed? (If so, please list the procedure, the reason performed, the hospital and date performed and the surgeon s name if possible) Procedure Reason Performed Location/Date Surgeon Do you have at present (or have you ever had) any known medical problems for which you have been followed and treated by a physician (for example, high blood pressure, diabetes, heart problems, gout, etc ) Medical problem Year Diagnosed Years Treated 6. Have you ever been hospitalized for something other than a surgical procedure? (If so, for what reason, when/where, and under the care of whom?) Reason When/Where Attending Physician MEDICATIONS Name of Drug Dose Length Taken Has it Helped? A Lot Some None PERSONAL HABITS Do you consume alcoholic beverages? Yes No If so, approximately how much per day? Do you use tobacco products? How many hours do you work per week? Hrs. Yes No If so, what type, for how long, and how much? Do you consider your work: Satisfying Stressful Excessively Tiring What other jobs have you held during your lifetime? Do you exercise? Yes No If so, what type of exercise and how much? How many hours of sleep do you get per night? Do you feel rested when you awaken? Yes No

3 FAMILY MEDICAL HISTORY Please list age now, (or at the time of death), state of health or cause of death, for the following family members: Mother Maternal Grandmother Maternal Grandfather Father Paternal Grandmother Paternal Grandfather Brothers/Sisters (Indicate sex) M / F Children Spouse M / F M / F M / F Age If Living Health (such as cancer, diabetes, bleeding) If Deceased Age Cause EDUCATION (Check highest level attended) Grade School Junior High School High School College Graduate School HOME CONDITIONS On the scale below, check the number which best describes your situation; most of the time I function: 1 Very Poorly 2 Poorly 3 Okay 4 Well Very Well What is the hardest thing for you to do physically? Are you receiving Disability? Yes No Are you applying for Disability? Yes No Do you have a medically-related lawsuit pending? Yes No

4 REVIEW OF SYSTEMS Please mark any problems you have or have had in these areas: HEENT GU ENDOCRINE Cataract Nephritis Thyroid Disease Glaucoma Kidney Infection Diabetes Migraine Headaches Syphilis HEMA/ONC Sinus Infections Gonorrhea Any Kind of Cancer (Type ) HEART Genital Herpes Anemia Rheumatic Fever MS Blood Transfusion Heart Attack Rheumatoid Arthritis Blood Clots Angina Gout Bleeding Tendency Heart Failure Lupus OTHER Heart Palpitations Serious Joint Injury Alcoholism High Blood Pressure Broken Bones Drug Abuse LUNG Disabling Back Pain AIDS/HIV Asthma Degenerative Arthritis Other Pneumonia Osteoporosis WOMEN ONLY Pleurisy SKIN Pregnancy (# of times ) Blood Clot in Lung Skin Ulcer Lower Leg Miscarriage (# of times ) Tuberculosis Fingers Turning White Toxemia / Eclampsia GI Stomach / Duodenal Ulcer Cirrhosis Hepatitis Gallstones Pancreas Disease Intestinal Polyp Esophagus Disease Colitis Diverticulitis Diarrhea Psoriasis NEURO/PSYCH Meningitis Stroke / Paralysis Seizure / Epilepsy Depression Nervous Breakdown

5 REVIEW OF SYSTEMS (Cont d) Please mark any problems you have or have had in these areas: GENERAL CARD/PULM MS / NEURO Weight Gain Chronic Cough Joint Pain Weight Loss Coughing Up Blood Joint Swelling Poor Appetite Shortness of Breath Stiff Muscles Fever, Chills, Sweats Chest Pain Painful Muscles Swollen Glands GI Weak Muscles New Lump or Growth Heartburn Numbness Feeling Fatigue Nausea and/or Vomiting SKIN Trouble Sleeping Stomach/Abdominal Pain Rash Problems with the Sun Constipation Skin Ulcers Hair Loss Diarrhea Bumps On Skin Hair Overgrowth Bleeding From Rectum Tick Bites HEENT Loss of Vision Dry Eyes Redness in Eyes Headaches Ringing in Ears Loss of Hearing Nasal Congestion Dry Mouth Trouble Swallowing Mouth Sores / Ulcers Recent Tooth Pulled Hoarseness Black Bowel Movement GU Problems Passing Urine Urine Leak Blood In Urine Burning on Urination Discharge From Penis Discharge From Vagina Sores on Genitals Menstrual Problems I May Be Pregnant Breast Lump

RHEUMATOLOGY PATIENT HISTORY FORM

!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant