Athens Rheumatology Clinic, LLC Sana Makhdumi, MD Phone: 706-850-8322 Fax: 706-850-8322 PATIENT HISTORY FORM Date of first appointment: / / Time of appointment: Birthdate: Name LAST FIRST MIDDLE INITIAL MAIDEN Address: Age: Sex: F M STREET Telephone: Home ( ) CITY STATE ZIP Work ( ) MARITAL STATUS: Never Married Married Divorced Separated Widowed EDUCATION (Circle highest level attended) Grade School 7 8 9 10 11 12 College 1 2 3 4 Social Security Occupation Number of Hours worked Referred by: (Check one) Self Family Friend Doctor Language used: Name of person making referral: Name the physician providing your primary medical care: Describe your present symptoms: Symptoms began when: Left Right Have you been treated with any of the following? (Physical therapy, Surgery and Injections; Medications _ Have any other doctor seen you for this problem? 1
RHEUMATOLOGIC (ARTHRITIS) HISTORY Have (You or Family Member) had any of the following? (Check if yes ) Yourself Family Member Yourself Family member Arthritis Osteoarthritis Gout Childhood arthritis Lupus or SLE Rheumatoid Arthritis Ankylosing Spondylitis Osteoporosis Other arthritis: Date of last eye exam Date last chest x-ray Date of last Tuberculosis Test Date of last bone densitometry SYSTEMS REVIEW: Please check any problems, which affects you. Any Major Gastrointestinal Integumentary (skin and breast area) weight gain Nausea Easy Bruising weight loss Vomiting of blood Redness Fever Stomach pain Rash or Hives Fatigue / Weakness Jaundice Nodules/bumps Constipation Persistent diarrhea Sun sensitive Hair loss Bloody or Black stools Color change in hands / feet in the cold Eyes Glaucoma Heartburn Genitourinary Cataracts Blood in urine Neurological System Loss of vision Difficult urination Stroke Double or blurred vision Pain or burning on urination Dizziness or Fainting Dryness / Itching Rash/ Ulcers Memory loss Feels like something in eye Cloudy or Pus in urine Kidney disease Muscle spasm Nervous breakdown Loss of consciousness Ears-Nose-Mouth-Throat Discharge from penis/vagina Sensitivity or pain of hands or feet Ringing in ears Prostate trouble Epilepsy Loss of hearing Nosebleeds Sexual difficulties Loss of smell Thyroid Problem Cardiovascular Musculoskeletal Dryness in nose or mouth Hyperthyroid Chest Pain Morning stiffness Loss of taste Agitation Hypothyroid Irregular heart beat Muscle weakness 2 High blood pressure Heart attack Joint swelling Joint pain
For Women only: Periods regular? YesNo Date of last pap? & Date of last period? Date of last mammogram Have you had any bleeding after menopause? YesNo Number of miscarriages? and Number of Pregnancies? Have you had Blood Transfusion-when/ and where: SOCIAL HISTORY How much coffee do you drink? Do you smoke? Yes No How long? Do you drink alcohol? Yes No Number per week Do you use drugs for reasons that are not medical? Yes No -If yes, please list: Do you exercise regularly? Yes No How many hours of sleep do you get at night? Do you have an orthopedic surgeon? No Yes- if yes, Name: Please list any orthopedic surgeries: Any previous fractures? Yes No Describe: Any other serious injuries? Yes No Describe: Emergency Contact: FAMILY HISTORY: Father Mother IF LIVING Age Health Age at Death IF DECEASED Cause 3 Number of siblings Number living Number deceased
MEDICATIONS Name of Drug Dose (include strength & number of pills per day) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Pharmacy: Name and Number Drug Allergies? No Yes: To what and its reaction? Can you do the following: No Problems Some Problems Unable to do a. Write, and dress yourself? b. Get in and out of the car? c. Lifting a plate and cook? d. Walking for 2-4 hours? f. Bending elbow, hip and knees with any problems? g. Turn the shower on and off? How severe is your pain: No pain 0 1 2 3 4 5 Very Bad 4 Sana Makhdumi, MD