Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of Christie Clinic at 1801 West Windsor Road, Champaign, IL 61822. Please complete the enclosed questionnaire and bring it with you to your appointment. Please arrive 30 minutes prior to your appointment time. Be sure to have the attached questionnaire completed and with you are your appointment. If you do not have the paperwork at your appointment, you will be asked to reschedule. This consultation and evaluation requires review of outside records and tests pertaining to the problem for which you are being seen. We ask that you contact your referring physician and ask that your information pertinent to this appointment, such as clinic notes, hospital records, lab results, x-ray films and reports, other imaging reports (CT, MRI, etc.) are faxed to 217-351-1290. Please ask your referring physician to include in the fax the physicians name, address and telephone number for future correspondence concerning your care. Delay in receiving outside records might delay your appointment with Dr. Kohli. It might even become necessary to postpone your consultation if the records are not received in a timely manner. Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan. If you are unable to keep your appointment, please notify my office at least 24 hours in advance at 217-366-5434 Thank you for your assistance. Sincerely Manoj Kohli, M.D. 217-366-5434 Office 217-351-1290 Fax 2
RHEUMATOLOGY HISTORY Manoj Kohli, M.D. Board Certified Rheumatologist 1801 W. Windsor Road Champaign, IL 61822 (217)366-5434 Office 217-3351-1290 (Fill out in ink only) Name: Age: Referring Physician: Appointment Date: Reason for Today s Visit: Please indicate all of the locations of your pain OVER THE PAST WEEK by shading the body figures and the hands. 3
SOCIAL HISTORY RACE: Asian Hispanic Black White Other MARITAL STATUS: Single Married Divorced Separated Widowed TOBACCO: Never Smoked Current Use How much per day? How many years? Past use If you have stopped smoking, when did you stop? How many years did you smoke? How much per day did you smoke? ALCOHOL : If daily use, how much? Occasional Never COFFEE : How much per day? Decaf Never COLA: How much per day? Decaf Never TEA: How much per day? Decaf Never 1. What is your current occupation? (If you are not working now, what was your past occupation?) 2. At this time, are you: (please check all that apply) Working full time Working part time Homemaker-full time Homemaker- need help from others Retired Student Disabled Other (describe) 3. What is the highest level of education that you have? 4. How many living children do you have? Male Female 5. Please indicate the name, address, and telephone number of someone who lives at a different address from you and who will likely know your whereabouts if we are unable to reach you. Name Telephone Address Relationship GYNECOLOGICAL HISTORY Number of Pregnancies? Number of births? Any miscarriages? Yes No If so how many? Date of last menstrual period? Date of last Pap smear? Date of last mammogram? Breast self exam? Yes No Have you ever taken hormones? Yes No If yes, list medication and how long you took it: IMMUNIZATION Date last immunized? Flu Pneumonia 4
PAST ILLNESS AND FAMILY HISTORY Please place an X if you have been told by a doctor that you have any of the listed conditions. Please indicate if any family member(s) have had this condition using the following key in the column marked FM: F = father S = sister GF = grandfather U = uncle M = mother B = brother GM = grandmother A = aunt Condition You FM Condition You FM Condition You FM Hypertension(blood Asthma Alcohol Problem Pressure) Heart Attack COPD Drug Problem Congestive Heart Failure Diabetes Irregular/Fast Heart Beat TB Thyroid Problems Rheumatic Fever Positive TB Skin Arthritis Test Stomach/Duodenal Ulcers Neurologic Osteoporosis Condition Ulcerative Colitis/Crohn s Stroke Fracture (broken bones) Irritable Bowel Syndrome Neuropathy Iritis (Uveitis) Liver Disease Parkinson s Disease Sexually transmitted disease Kidney Condition Seizures Female GYN Problems Kidney Stones Mental/Psychiatric Blood Clots Migraine Headaches Others: Please list Cancer Depression Psoriasis Anxiety If you were hospitalized or had surgery, please list the condition & the month/year in which you received treatment. Condition Month/Year Condition Month/Year CURRENT MEDICATION Name of drug or medicine Dose if known How many times daily? Name of drug or medicine Dose if known How many times daily? Please list any DRUG ALLERGIES and type of reaction below: 1. 3. 2. 4. 5
REVIEW OF SYSTEMS Please check ( ) if you have experienced any of the following OVER THE PAST SIX MONTHS OR SINCE YOUR LAST VISIT: Constitutional Weight Gain Weight Loss Change in Eating Habits Unusual Fatigue Fever Eyes Double Vision Loss of Vision Dry Eyes Eye Pain Red Eyes Ear, Nose and Throat Hearing Loss Ringing in Ears Sinus Trouble Hoarseness Sores in Mouth Dry Mouth Dizziness Cardiovascular Chest Pain Palpitations Leg Swelling Fainting Spells Respiratory Dry Cough Cough with Phlegm Phlegm with Blood Wheezing Shortness of Breath Gastrointestinal Heart Burn Abdominal/Stomach Pain Difficulty Swallowing Vomiting Diarrhea Constipation Blood in Bowel Movement Jaundice Genitourinary Painful Urination Frequent Urination Difficulty Passing Urine Excessive Urination at Night Blood in Urine Hernia Change in Menstrual Cycle Sexual Problems Skin Difficulty Tolerating the Sun Fingers Turning Colors in Cold Loss of Hair Skin Rash/Hives/ Skin Sores Neurological Frequent or Severe Headaches Problem Sleeping Tremors Difficulty Walking Loss of Balance Numbness Weakness Loss of Consciousness Seizures Psychiatric Feeling of Anxiety (Nervous) Feeling of Depression Crying with Spells Loss of Interest in Usual Activities Difficulty with Memory, Concentration or Decision-making Hematological/Lymphatic Swollen Glands Anemia Abnormal Blood Counts Unusual Blood Counts Unusual Bruising Other Excess Bleeding Blood clots All non-checked items were reviewed and were negative. Manoj Kohli, M.D. 6