LIST ALL CURRENT MEDICATIONS BELOW INCLUDING INJECTIONS/INFUSION MEDICINES MEDS) Name of Medication Dose How often taken

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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: CURRENT MEDICATIONS (INCLUDE VITAMINS, SUPPLEMENTS, AND OVER THE COUNTER LIST ALL CURRENT MEDICATIONS BELOW INCLUDING INJECTIONS/INFUSION MEDICINES MEDS) Name of Medication Dose How often taken 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. *use an additional sheet of paper if necessary. CAL PROBLEMS FILL OUT YOUR ALLERGIES BELOW- MUST COMPLETE AT EACH VISIT Ingredient/Allergen Type of allergic reaction rash trouble breathing stomach discomfort other: rash trouble breathing stomach discomfort other: rash trouble breathing stomach discomfort other: rash trouble breathing stomach discomfort other:. Review of Symptoms: Please mark the symptoms you have been having recently. Check all boxes that apply 1 GENERAL fever chills fatigue weight loss insomnia EYES vision loss dry eyes EAR/NOSE/THROAT nasal drainage mouth sores RESPIRATORY shortness of breath cough History of tuberculosis PPD positive CARDIOLOGY chest pain palpitations VASCULAR leg swelling/edema Raynaud s GASTROENTEROLOGY nausea heartburn vomiting diarrhea swallowing constipation blood in stool black tarry stool UROLOGY painful urination blood in urine ENDOCRINE heat intolerance cold intolerance hair loss NEUROLOGY headache tingling/numbness gait difficulties dizziness memory loss seizures PSYCHOLOGY emotional problems concentrating SKIN rash sun sensitivity MUSCULOSKELETAL joint stiffness joint pain joint swelling muscle pain muscle weakness back pain neck stiffness BLOOD/LYMPH swollen glands easy bruising

HEALTH MAINTENANCE, Last Pneumonia Vaccine Date Don t Know Never had one Declined Have you had a Flu shot within the last year? No Yes Date Don t Know Declined Last Bone Density (DEXA): Date Results: Normal Osteopenia Osteoporosis Don t Know OR Never had one Declined Last Chest X-ray Date Results: Normal Abnormal Don t Know OR Never had one Declined Shingles Vaccine: Yes Date: No Declined Tuberculosis test (PPD/Quantiferon Gold test): Yes Date: No APPLY, Medical History/Current Medical Problems (Check all that apply, fill in any others) Osteoarthritis Rheumatoid Arthritis Polymyalgia Rheumatica (PMR) Osteoporosis Spinal Stenosis Rotator Tendonitis / Tear Bursitis Fibromyalgia Lupus Prostate Problems Bladder Problems Kidney disease Sjogren s Syndrome Crohn s Disease Ulcerative Colitis Celiac Disease Gout High Blood Pressure Diabetes Type 1 or Type 2 Heart Disease: Heart Attack Atrial Fibrillation High cholesterol Emphysema / Asthma Reflux / GERD Stomach/GI problems: Depression Thyroid disorder Cancer, type Psoriasis Broken bone(s)? E Women s Health: Currently pregnant? Yes No Number of pregnancies Number of miscarriages Number of live births Age at Menopause Hysterectomy? Yes No ALLERGIES SURGERY HISTORY Date SURGERY HISTORY Date angioplasty or stent open heart pacemaker gastrointestinal lung surgery prostate surgery breast surgery other Joint Surgery: Fill all boxes that apply. THIS IS SURGERY ONLY-NOT JOINT PAIN OR SYMPTOMS Hip Rt or Lt Knee Rt or Lt Hand/Wrist Rt or Lt Carpal tunnel Rt or Lt Shoulder Rt or Lt Elbow Rt or Lt Foot/ankle Rt or Lt Neck Low back Other Dates: 2

On each row below, please read the diseases and then fill the boxes under any family members who have had it. Family History Conditions/Problems Father Mother Brother Sister Child Diabetes High Blood Pressure Osteoporosis Rheumatoid arthritis Childhood arthritis Heart Problems Cancer Gout Psoriasis or psoriatic arthritis Lupus Osteoarthritis Fibromyalgia Thyroid disease Multiple Sclerosis Other 3 Social History/Habits Race: Hispanic Non-Hispanic Decline to report Primary Language Spoken At Home English Other Education: (circle highest level attended): Grade School 7 8 9 10 11 12 College 1 2 3 4 Graduate School Occupation: Retired Disabled: Year of Disability Reason for disability Married Widowed Divorced Single Significant Other Children: Yes No Smoking: NO Yes packs/day Quit smoking in Never smoked Alcohol use: No Yes (drinks/week: ) Have you had any falls within the last year? No Yes If yes, how many? Exercise freuency: Never Occasional Daily 2-3 times/week 3-4 times/week Type of exercise: Living Will: No Yes Healthcare Proxy No Yes Power of Attorney: No Yes Name: Relationship:

4 Referring Physician: PH: Address: Reason for visit: Joint pain Joint swelling Abnormal lab test Abnormal bone density Pain all over Length of symptoms: 0-3 months 3-6 months 6-12 months >1 year # Days of work missed last month due to arthritic condition: (Leave blank if not employed or retired) Over the last week, were you able to: Without ANY With SOME With MUCH UNABLE to do Dress yourself, including tying shoelaces and doing buttons? 0 1 2 3 Get in and out of bed? 0 1 2 3 Lift a full cup or glass to your mouth? 0 1 2 3 Walk outdoors on flat ground? 0 1 2 3 Wash and dry your entire body? 0 1 2 3 Bend down and pick up clothing from the floor? 0 1 2 3 Turn regular faucets on and off? 0 1 2 3 Get in and out of a car, bus, train or airplane? 0 1 2 3 Walk two miles if you wish? 0 1 2 3 Participate in recreational activities and sports as you would like, if you wish? 0 1 2 3 (for office use only: MDHAQ score ) 1. 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 PAIN AS BAD AS IT COULD BE 2. How tired have you been OVER THE PAST WEEK? Please indicate how severe your fatigue has been: NO PROBLEM VERY TIRED 3. 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 VERY POORLY

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