HAQ-II(Health Assessment Questionnaire-II)

Similar documents
New Patient Registration Form Rheumatology - Dr. Mary Olsen, MD. Insurance Information. DOB: Relationship to Patient: DOB: Relationship to Patient:

Patient History Form

Patient History Form

Last First Middle Initial Maiden Month/Day/Year. Address: Age: Sex: F M Street Apt. # Telephone: Home City State Zip Work

Name: Birthdate: / / LAST FIRST MIDDLE mm dd yyyy. Address: STREET CITY APT # STATE ZIP. Name of Person Making Referral:


Patient History Form

Birthdate: / / Address: Age: Sex: M F. Telephone: H ( ) City State Zip W ( ) C ( )

Welcome to our Practice! We appreciate you choosing us for you healthcare needs.

Patient History Form

Welcome to our Practice! We appreciate you choosing us for you healthcare needs.

New Patient History Form Today s Date:

Charles H. Boniske MD Inc W. Hillsdale Ave. Visalia, CA

Date of first appointment: / / Name: Birthdate: / / LAST FIRST MIDDLE INITIAL MAIDEN MONTH DAY YEAR Address: Age: Sex: F M Telephone: Home ( )

Date of first appointment: Month: Day: Year: Time of appointment: First Name Lastname Middle Initial Maiden. Birthdate: Month: Day: Year: Address:

Athens Rheumatology Clinic, LLC Sana Makhdumi, MD

RHEUMATOLOGY ASSOCIATES

SCOTT J. ZASHIN, M.D., P.A. RHEUMATOLOGY (214) FAX (214)

Dr. Gina Del Giudice, M.D., FACR, FACP Michael J. Froncek, M.D., MS, FACP, FACR INITIAL PATIENT HISTORY AND HEALTH ASSESMENTS

Greensboro Medical Associates, PA 1511 Westover Terrace Suite 201 Greensboro, NC Date of first appointment:

Patient History Form

Consent Form and HIPAA Privacy Notice. Practice's Consent Form: Practice's HIPAA Privacy Notice:

NEW PATIENT DEMOGRAPHICS QUESTIONNAIRE

NEW PATIENT INFORMATION

RHEUMATOLOGY PATIENT HISTORY FORM

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.

New Patient Urologic History Form

Helpline No:

NSAID all (Warner-Schmidt) includes all (NSAIDs, Salicytes, and Cox-2 inhibitors)

Directions: ~RdNE'" SANTA ~

NSAIDs. NSAIDs are important but they can have side effects.

Have you ever had a bone density test in the past? YES / NO If yes, when, where and what type (DXA, ultrasound or QCT)?

Molland Spinal Care, LLC 124 Hwy 35 South Red Bank, NJ Phone:

Notto Chiropractic Health Center Patient Information

Month/Year of Review: January 2012 Date of Last Review: February 2007

KAREN J. SUNDBY, M.D. PLEASE COMPLETE THE FOLLOWING MEDICAL HISTORY FORM

Physician initials. Date: / / Birthdate: / / Age: Sex: F M

WELCOME TO AGEWELL MEDICAL ASSOCIATES

Schodack Internal Medicine and Pediatrics. Annual Physical-Female

**************************************************************************

WELCOME TO AGEWELL MEDICAL ASSOCIATES

A L L F L O R I D A P O D I A T R Y, P. A. M A R C G. C O L A L U C E, D. P. M.

2018 WPS MedicareRx Plan (PDP) Step Therapy

CHEMICAL DEPENDENCY CLINIC

Gender: Male Female Age: Current Address: City: State: Zip Code: Work Phone: Is it okay to leave a message? VISIT INFORMATION

To all patients covered by Medicare,

Patient Information (Please Print)

Thank you for calling the Osteoporosis Assessment Center to schedule your DEXA (bone mineral density study) appointment on.

PATIENT INFORMATION SHEET

COLCRYS-PST. Products Affected Step 1: Mitigare 0.6 mg capsule. Details. Step 2: Colcrys 0.6 mg tablet

Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other. Address City/State/Zip Phone # (home) (cell)

Welcome to Medina Family Chiropractic and Acupuncture!

NOTICE TO OUR PATIENTS

PATIENT INFORMATION FORM

Coastal Arthritis and Rheumatism Associates PATIENT REGISTRATION

Morin Chiropractic P.A. Dr. Paul N. Morin, D.C. 862 Minot Avenue Auburn, ME (207) Fax (207)

Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:

311 North M.D. First Name. Race: Asian. White. Name. Phone: Coverage: made. Name Relationship

The Muscatine Study Heart Health Survey

Seminar Information Page

SLRHC Cardiovascular Prevention Program - Cardiovascular Health Questionnaire

New Patient Health Information

HEALTH QUESTIONNAIRE

eappendix A. Opioids and Nonsteroidal Anti-Inflammatory Drugs

Primary Care Demographic and Medical History Form

PRE-VISIT QUESTIONNAIRE

Index. Note: Page numbers of article titles are in boldface type.

New Patient Questionnaire

First Name. Specialty: Fax. First Name DOB: Duration:

Initial Patient Self Assessment Demographics:

HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES

HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES HUMIRA PEDIATRIC

COLCRYS-PST. Products Affected Step 1: Mitigare 0.6 mg capsule. Details. Step 2: Colcrys 0.6 mg tablet

Drug Class Review on Cyclo-oxygenase (COX)-2 Inhibitors and Non-steroidal Anti-inflammatory Drugs (NSAIDs)

Foot & Ankle Doctors, Inc.

NEW PATIENT HEALTH HISTORY

CITY OF HOPE NATIONAL MEDICAL CENTER QUALITY OF LIFE QUESTIONNAIRE FOR PATIENTS WITH AN OSTOMY

Welcome to the Healthplex!

Patient s Name Date: Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other

Margie Petersen Breast Center

Rheumatoid Arthritis

Patient Registration Form

WELCOME TO OUR OFFICE

*** ADDRESS: (If address is not provided, you MUST write Patient denied.)

Race (Check one): White Black Asian American Indian/Eskimo/ALEU Hawaiian Native/Pacific Islander Other

PATIENT REGISTRATION FORM

PRE-VISIT QUESTIONNAIRE FOR NEW PATIENTS

HEALTH HISTORY QUESTIONNAIRE. Family Risk Assessment Program

Please review the below items in preparation for your visit.

PLEASE FILL OUT & RETURN

Name: Date of Birth: Address: City: State: Zip Code: Phone Number: Cell Phone: Work Number: Race: Primary Language: Secondary Language:

Patient Follow-up Form - Version 1.1

Alzheimer Disease Research Center

Large Granular Lymphocyte (LGL) Leukemia Registry Page 1 of 6 PATIENT INFORMATION QUESTIONNAIRE

Adult Demographics Form

Medicare Annual Wellness Visit Questionnaire

Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:

PERSONAL HISTORY NAME TODAY S DATE LAST FIRST MI LIST ANY ADDITIONAL NAMES USED: ADDRESS PHONE (STREET) (CITY) (STATE) (COUNTY) (ZIP)

Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: Spouse/Partner Name:

Patient Information. Name: (Last) (First) (Middle) Address: (Street) (City) (State) (Zip) Home Phone: Cell Phone: address:

Transcription:

Kathy Karamlou, MD 355 Placentia Ave, suite 208 Newport Beach, CA 92663 949-631-6500 949-631-9700 NAME: DATE: DOB: HAQ-II(Health Assessment Questionnaire-II) We are interested in learning how your illness affects your ability to function in daily life. Place an X in the box which best describes your usual abilities OVER THE PAST WEEK. Are you able to: Without any difficulty (0) With some difficulty (1) With much difficulty (2) Get on and off the toilet? o o o o Open car doors? o o o o Stand up from a straight chair? o o o o Walk outdoors on flat ground? o o o o Wait in a line for 15 minutes? o o o o Reach and get down a 5-pound object (such as a bag of sugar) from just above your head? Unable (3) o o o o Go up 2 or more flights of stairs? o o o o Do outside work (such as yard work)? o o o o Lift heavy objects? o o o o Move heavy objects? o o o o TOTALS: SCORE: (STAFF WILL CALCULATE) To score, add all items and divide by the number of questions answered. Must answer a minimum of 7 Scores range from 0-3

Patient History Form Date of first appointment: / / month day year Name: Address: last first middle initial maiden street apt # city state zip Time of appointment: Birthplace: Birthdate: / / month day year Age Sex: F M Telephone: Home: ( ) Work: ( ) MARITAL STATUS: Never Married Married Divorced Separated Widowed Spouse/Significant Other: Alive/Age Deceased/Age Major Illnesses: Email: Occupation Number of hours worked/average per work: Referred here by: (check one) Self Family Friend Doctor Other Health Professional Name of person making referral: The name of the physician providing your primary medical care: RHEUMATOLOGIC (ARTHRITIS) HISTORY At any time have you or a blood relative had any of the following? (check if yes ) Yourself Arthritis (unknown type) Osteoarthritis Gout Childhood Arthritis Relative Name/Relationship Yourself Lupus or SLE Rheumatoid Arthritis Ankylosing Spondylitis Osteoporosis Relative Name/Relationship Other arthritis conditions: Social History Do you smoke? Yes No Past How long ago? Has anyone ever told you to cut down on your drinking? Yes No Do you drink alcohol? Yes No Number per week Do you exercise regularly? Yes No Type Amount per week FAMILY HISTORY IF LIVING IF DECEASED Age Health Age at Death Cause Father Mother Number of sisters Number living Number decreased Number of brothers Number living Number decreased List ages of each Health of children

PAST MEDICAL HISTORY 1. 2. 3. 4. 5. 6. 7. 8. PREVIOUS SURGERIES Type Year Reason 1. 2. 3. 4. 5. 6. 7. Any previous fractures? No Yes Describe: Any other serious injuries? No Yes Describe: MEDICATIONS Drug allergies: No Yes If yes, please list: Type of reaction: PRESENT MEDICATIONS (List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium and other supplements, etc.) Name of Drug Dose (include strength & number How long have you taken this Please check: Helped? of pills per day) medication A Lot Some Not At All 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

PAST MEDICATIONS: Please review this list of arthritis medications. As accurately as possible, try to remember which medications you have taken, how long you were taking the medication, the results of taking the medication and list any reactions you may have had. Record your comments in the spaces provided. Drug names/dose Length of time Please check: Helped? A Lot Some Not At All Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Circle any you have taken in the past Reactions Flurbiprofen Diclofenac + misoprostil Aspirin (including coated aspirin) Celecoxib Sulindac Oxaprozin Salsalate Diflunisal Piroxicam Indomethacin Etodolac Meclofenamate Ibuprofen Fenoprofen Naproxen Ketoprofen Tolmetin Choline magnesium trisalcylate Diclofenac Pain Relievers Acetaminophen Codeine Propoxyphene Disease Modifying Antirheumatic Drugs (DMArDS) Certolizumab Golimumab Hydroxychloroquine Penicillamine Methotrexate Azathioprine Sulfasalazine Quinacrine Cyclophosphamide Cyclosporine A Etanercept Infliximab Tocilizumab Osteoporosis Medications Estrogen Alendronate Etidronate Raloxifene Fluoride Calcitonin injection or nasal Risedronate Gout Medications Probenecid Colchicine Allopurinol Others Tamoxifen Tiludronate Cortisone/Prednisone Hyaluronan Herbal or Nutritional Supplements

Name: Ethnicity: Non-Hispanic, Hispanic, or Not Specified (circle one) Preferred Language: Race: (Check all that apply) African or African American Asian or Asian American Caucasian or European American Native American or Native Alaskan Native Hawaiian or Other Pacific Islander Other Race

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback