RHEUMATOLOGY ASSOCIATES

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Transcription:

RHEUMATOLOGY ASSOCIATES Patient History Form Date of first appointment: / / Time of appointment: Birthplace: MONTH DA Y YEAR Name: Birthdate: / / LAST FIRST MIDDLE INITIAL MAIDEN MONTH DAY YEAR Address: Age: Sex: F M STREET APT# Telephone: Home ( ) CITY STATE ZIP 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: Do you have an orthopedic surgeon? Yes No If yes, Name: Describe briefly your present symptoms: Example: Please shade all the locations of your pain over the past week on the body figures and hands. Date symptoms began (approximate): Previous treatment for this problem (include physical therapy, surgery and injections; medications to be listed later) Please list the names of other practitioners you have seen for this problem: Diagnosis given: Adapted from CLINHAQ, W olfe F and Pincus T. Current Comment Listening to the patient A practical guide to self report questionnaires in clinical care. Arthritis Rheum. 1999;42 (9):1797-808. Used by permission. RHEUMATIC DISEASE (ARTHRITIS) HISTORY At any time have you or a blood relative had any of the following? (check if yes ) Yourself Relative Name/Relationship Yourself Arthritis (unknown type) Osteoarthritis Gout Childhood arthritis Fibromyalgia Other arthritis conditions: Lupus or SLE Rheumatoid Arthritis Ankylosing Spondylitis Osteoporosis Chronic fatigue syndrome Relative Name/Relationship - 1 -

REVIEW OF SYSTEMS As you review the following list, please check any of those problems which have significantly affected you. Musculoskeletal Morning stiffness Psychiatric Excessive worries Neurological System Numbness or tingling in hands Lasting how long? Anxiety Numbness or tingling in feet Minutes Hours Panic attacks Headaches Joint pain Joint swelling Easily losing temper Depression Dizziness Fainting List joints affected in the last 6 mos. Agitation Muscle spasm Muscle weakness Muscle tenderness Difficulty falling asleep Difficulty staying asleep Gastrointestinal Nausea Vomiting Abdominal pain Heartburn Cramping in legs at night Memory loss Endocrine Excessive thirst Hematologic/Lymphatic Blood clot in artery, vein, or lung Bleeding tendency Constitutional Diarrhea Enlarged lymph nodes Generalized weakness Fatigue Mucus in stools Unusual constipation Anemia Transfusion/when Fever or chills Blood in stools Allergic/Immunologic Night sweats Recent weight loss amount Recent weight gain Eyes Black/tarry stools Genitourinary Difficulty urinating Blood in urine Frequent sneezing Increased susceptibility to infection Ears Nose Mouth Throat Dryness of mouth amount Pain or burning on urination Sinus pain Loss of vision Pus in urine Cloudy urine Difficulty swallowing Sores in mouth Double or blurred vision Sexual difficulties Ringing in ears Redness Pain Dryness Feels like something in the eye Genital rash/ulcers For Women Only: Vaginal dryness Vaginal discharge Loss of hearing Nosebleeds Loss of smell Bleeding gums Itching eyes Date of last period? / / / Loss of taste Dermatology Thickness Tightness Rash Number of pregnancies? Number of miscarriages? For Men Only: Discharge from penis Frequent sore throats Hoarseness Cardiovascular Chest pain Unexpected hair loss Prostate trouble Difficulty in breathing at night Sun sensitive (sun allergy) Redness Respiratory Shortness of breath Cramping in calves when walking Swollen legs or feet Hives Cough Color changes of hands in the cold Nodules/bumps Nail pits Difficulty breathing at night Coughing of blood Wheezing (asthma) Irregular heart beat Sudden changes in heart beat Heart murmurs Please state the date of your last: Bone Densitometry / / Mammogram / / Eye exam_ / / Chest x ray / / Tuberculosis Test / / Flu Vaccine / / Pneumonia Vaccine / / Tetanus Vaccine / / Shingles Vaccine / / Hepatitis B Vaccine / / - 2 -

YOUR PAST MEDICAL HISTORY: Have YOU ever been diagnosed with any of the following diseases? Cancer/Leukemia/Lymphoma Heart Disease Diabetes High blood pressure High Cholesterol Stroke Emphysema/COPD/Asthma Kidney disease Thyroid disease Jaundice/Hepatitis Tuberculosis Pneumonia HIV/ AIDS Headaches/Migraines Depression Nervous Breakdown Glaucoma Anemia Rheumatic Fever Epilepsy Psoriasis Colitis Iritis/Uveitis Sarcoidosis Other significant illness (not listed above): Previous Operations/ Surgical History Type Year Reason 1. 2. 3. 4. 5. 6. 7. Any previous fractures? No Yes Describe: Any other serious injuries? No Yes Describe: FAMILY HISTORY: IF LIVING IF DECEASED Year of Birth Health Age at Death Cause Father Mother Number of sisters Number living Number deceased Number of brothers Number living Number deceased Number of daughters Number living Number deceased Number of sons Number living Number deceased Health of children: Do you know of any close blood relative (parent, sibling or child) who has or had: (check and give relationship) Cancer Heart disease Rheumatic fever Tuberculosis Leukemia High blood pressure Epilepsy Diabetes Stroke Bleeding tendency Asthma Goiter Colitis Alcoholism Psoriasis SOCIAL HISTORY: Marital Status: Never Married Married Divorced Separated Widowed Spouse/Significant Other: Alive/Age Deceased/Age Major Illnesses How many people in household? Relationship and age of each Education (circle highest level attended): Grade School 7 8 9 10 11 12 College 1 2 3 4 Graduate School Occupation Number of hours worked/average per week Do you drink caffeinated beverage? No Yes Cups/glasses per day? Do you smoke? No Yes Amount per day_ Do you drink alcohol? No Yes Number per week_ Recreational drug use? No Yes If yes please list Do you exercise regularly? No Yes Frequency_ Previous smoker? How long ago? Has anyone ever told you to cut down on your drinking? No Yes Please describe - 3 -

MEDICATIONS Drug allergies: No Yes To what? Type of reaction: PRESENT MEDICATIONS (List any medications you are taking. INCLUDE Over the Counter Medications as well, such items as aspirin, vitamins, laxatives, calcium and other supplements, etc.) Name of Drug Dose (include strength & number of pills per day) How long have you taken this medication Please check: Helped? - 4 - 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/dosage Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Length of time Please check: Helped? A Lot Some Not At All Ansaid (flurbiprofen) Arthrotec (diclofenac + misoprostil) Aspirin (including coated aspirin) Celebrex (celecoxib) Daypro (oxaprozin) Dolobid (diflunisal) Feldene (piroxicam) Indocin (indomethacin) Lodine (etodolac) Mobic (meloxicam) Motrin (ibupoprofen) Naprosyn (naproxen) Oruvail (ketoprofen) Voltaren (diclofenac) Other Pain Relievers Acetaminophen (Tylenol) Codeine (Tylenol 3) Hydrocodone (Vicodin, Lortab, Norco) Ultram/Ultracet (tramadol) Corticosteroids Decadron (dexamethasone) Medrol dose pack (methylprednisolone) Prednisone Cortisone injection (where) Disease Modifying Antirheumatic Drugs (DMARDS) Arava (leflunomide) Atabrine (quinacrine) Azulfidine (sulfasalazine) CellCept (mycophenolate mofetil) Reactions

DMARDS - Continued Cytoxan (cyclophosphamide) Imuran (azathioprine) Methotrexate (rheumatrex) Neoral or Sandimmune (Cyclosporine A) Plaquenil (hydroxychloroquine) Biologics Actemra (tocilizumab) Cimzia (certolizumab) Enbrel (etanercept) Humira (adalimumab) Kineret (anakinra) Orencia (abatacept) Remicade (Infliximab) Rituxan (rituximab): Simponi (golimumab) Osteoporosis Medications Actonel (risedronate) Boniva (ibandronate) Estrogen (Premarin, etc.) Evista (raloxifene) Forteo (teriparatide) Fosamax (alendronate) Miacalcin nasal spray (calcitonin) Prolia (denosumab) Reclast (zoledronic acid) Gout Medications Zyloprim (allopurinol) Colcrys (colchicine) Benemid (probenecid) Uloric (febuxostat) Krystexxa (pegloticase) Others Hyalgan/Synvisc/Orthovisc/Euflexxa injections Cymbalta (dyloxetine) Lyrica (pregabalin) Neurontin (gabapentin) Savella (milnacipran) Muscle Relaxers Sleep Medication Other anti-depressants: Have you participated in any clinical trials for new medications? Yes No If yes, list: - 5 -

ACTIVITIES OF DAILY LIVING Who does most of the housework? Who does most of the shopping? Who does most of the yard work? Because of health problems do you have difficulty: (Please check the appropriate response for each question.) Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do 1. Dress yourself, including tying shoelaces and doing buttons? 0 1 2 3 2. Get in and out of bed? 0 1 2 3 3. Lift a full cup or glass to your mouth? 0 1 2 3 4. Walk outdoors on flat ground? 0 1 2 3 5. Wash and dry your entire body? 0 1 2 3 6. Bend down to pick up clothing from the floor? 0 1 2 3 7. Turn regular faucets on and off? 0 1 2 3 8. Get in and out of a car, bus, train, or airplane? 0 1 2 3 9. Reaching behind your head? 0 1 2 3 10. Reaching behind your back? 0 1 2 3 11. Going to sleep? 0 1 2 3 12. Staying asleep due to pain? 0 1 2 3 13. Obtaining restful sleep? 0 1 2 3 14. Climbing stairs? 0 1 2 3 15. Descending stairs? 0 1 2 3 16. Working? 0 1 2 3 17. Getting along with family members? 0 1 2 3 18. Engaging in leisure time activities? 0 1 2 3 What is the hardest thing for you to do? Do you use a cane, crutches, as walker or a wheelchair? (circle one) Are you receiving disability?... Yes No Do you have a medically related lawsuit pending?...yes No Are you applying for disability?...yes No Considering that all of the ways your arthritis has affected you over the past week, please place a vertical mark on the line below to show how you are feeling: VERY GOOD 0 1 2 3 4 5 6 7 8 9 10 VERY POOR How much of a problem has UNUSUAL fatigue or tiredness been for you OVER THE PAST WEEK? Please circle on line below. NO PROBLEM 0 1 2 3 4 5 6 7 8 9 10 MAJOR PROBLEM How much pain have you had because of your condition OVER THE PAST WEEK? Please circle on the line below. NONE 0 1 2 3 4 5 6 7 8 9 10 AS BAD AS IT COULD BE - 6 -

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