ILLINOIS BONE AND JOINT INSTITUTE Rheumatology Medical History Form

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

ANDRES PEISAJOVICH MD 3820 MASTHEAD ST NE ALBUQUERQUE, NM PH: FAX:

Athens Rheumatology Clinic, LLC Sana Makhdumi, MD

Amarillo Surgical Group Doctor: Date:

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

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

HD CLINIC MEDICAL HISTORY FORM

RHEUMATOLOGY PATIENT HISTORY FORM

Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:

UnityPoint Clinic - Cardiology

Patient History Form

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS

New Patient Pain Evaluation

Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6

PATIENT HISTORY FORM

New Pulmonary Patient Questionnaire. Name Age Date. General Medical History

MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY

*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months

Past Surgical History

Questionnaire for Lipedema Patients

NEW PATIENT INFORMATION FORM

Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):

New Patient Information

MGH Beacon Hill Primary Care New Patient Form

PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM

Address Street Address City State Zip Code. Address Street Address City State Zip Code

SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET

DEEP BRAIN STIMULATION SURGICAL CANDIDACY EVALUATION FORM

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

New Patient Intake Form

Placer Private Physicians: Patient Health Questionnaire [2]

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT

Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.

Allina Health United Lung and Sleep Clinic

GoPrivateMD General Information & History

PULMONARY MEDICINE PATIENT QUESTIONNAIRE

NEW PATIENT QUESTIONNAIRE Spine pt acct #

GUPTA SPORTS & SPINE CENTER

DANA COKER KINGDON, PA

Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY

SANTA MONICA BREAST CENTER INTAKE FORM

N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro

Date of Visit / / Date of Birth / / Age

Name: Date: Street Address: Referring Physician: How long have you had your current problem?

Spine New Patient Questionnaire Rev

Gender: M F Race: Caucasian African American Hispanic Other

Providence Medical Group

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care

DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)

Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire

Southern Maine Integrative Health Center Adult Intake Form

GIDEON G. LEWIS, M.D.

Medical History Form

Mercy MS Center New Patient Information

NEW PATIENT REGISTRATION FORM

Headache Follow-up Visit Form

Welcome to About Women by Women

Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio

725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)

Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

Patient Intake Form for Allegany Ear, Nose, & Throat

Last Name First Name Middle Name MRN

MEDICAL QUESTIONNAIRE (male)

Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: I. What are you being seen for today?

PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION

Patient History (Please Print)

PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:

Providence Neurosurgery PATIENT INFORMATION SHEET

/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:

New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification

New Patient Information Form

THE OB/GYN CENTRE NEW PATIENT HISTORY

NEW PATIENT VISIT QUESTIONNAIRE

Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone

ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address

DIVISION OF CARDIOLOGY

PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.

LECOM Health Ophthalmology

Creve Coeur Family Medicine, LLC

Form.NewPatientHstory_PrecisionEndoRev Page 1 of 5

HEALTH HISTORY QUESTIONNAIRE

* CC* PATIENT QUESTIONNAIRE

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

Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency

Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA

FIRST TIME VISIT APPOINTMENT CHECKLIST Department of Radiation Oncology 200 Medical Plaza, Ste B265 Los Angeles, CA

SOC SEC #: - - Date of Birth: - - Age: yrs. State: Zip Code: Employer:

Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)

Thoracic Cardiovascular Institute

Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166

DATE: / / 7509 E. Main Street Reynoldsburg, Ohio Telephone: (614) Fax: (614)

I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.

Adult Demographics Form

N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro

Transcription:

ILLINOIS BONE AND JOINT INSTITUTE Rheumatology Medical History Form Name (Last, First, M.I.): M F DOB: Street Address: Home Telephone: Marital status: City: State: Zip Code: Work Telephone: Single Partnered Married Separated Divorced Widowed Referring doctor: PERSONAL HEALTH HISTORY Briefly state your reason for seeing the doctor today. Please describe your current symptoms, when it started, and what you have done for it: REVIEW OF SYSTEMS Please check mark whether you have had any of the conditions listed below over the LAST MONTH Constitutional Respiratory Neurological Fever Shortness of breath Dizziness Weight gain (>10 lbs) Wheezing Losing your balance Weight loss (>10 lbs) Cough Numbness or tingling or arms or legs Feeling sickly Gastrointestinal Weakness Fatigue Loss of appetite Musculoskeletal Head/Eye/Ear/Nose/Throat Heartburn or stomach gas Muscle pain, aches, or cramps Headaches Stomach pain or cramps Swelling of hands Dry eyes Nausea Swelling in other joints Blurred vision Vomiting Joint pain Wear glasses/contacts Constipation Back pain Problems with hearing Diarrhea Neck pain Ringing in the ears Dark or bloody stools Skin Stuffy nose Genitourinary Rash Sores in the mouth Problems with urination Hair changes Swollen glands Gynecological (female) problems Nail changes Dry mouth Blood in urine Psychiatric Lump in your throat Sexual problems Depression-feeling blue Problems with smell or taste Endocrine Anxiety-feeling nervous Trouble swallowing Excessive urination Problems with thinking Cardiovascular Heat/cold intolerance Problems with sleeping Pain the chest Hematologic Problems with memory Heart pounding (palpitations) Easy bruising Other problems: Swelling Easy bleeding

This questionnaire includes information not available from blood tests, X-rays, or any source other than you. Please try to answer each question, even if you do not think it is related to you at this time. Try to complete as much as you can yourself, but if you need help, please ask. There are no right or wrong answers. Please answer exactly as you think or feel. Thank you 1. Please check ( ) the ONE best answer for your abilities at this time: Without OVER THE LAST WEEK, were you able to: ANY With SOME With MUCH FOR OFFICE UNABLE USE ONLY To Do 1. a-j FN (0-10) a. Dress yourself, including tying shoelaces and doing buttons? 0 1 2 3 b. Get in and out of bed? 0 1 2 3 1=0.3 2=0.7 16=5.3 17=5.7 c. Lift a full cup or glass to your mouth? 0 1 2 3 3=1.0 4=1.3 18=6.0 19=6.3 d. Walk outdoors on flat ground? 0 1 2 3 5=1.7 6=2.0 20=6.7 21=7.0 e. Wash and dry your entire body? 0 1 2 3 7=2.3 8=2.7 22=7.3 23=7.7 f. Bend down to pick up clothing from the floor? 0 1 2 3 9=3.0 10=3.3 24=8.0 25=8.3 g. Turn regular faucets on and off? 0 1 2 3 11=3.7 12=4.0 26=8.7 27=9.0 h. Get in and out of a car, bus, train, or airplane? 0 1 2 3 13=4.3 14=4.7 28=9.3 29=9.7 i. Walk two miles or three kilometers, if you wish? 0 1 2 3 15=5.0 30=10 2. PN (0-10) j. Participate in recreational activities and sports as you would like? 0 1 2 3 4. PTGL (0-10) Get a good night s sleep? 0 1.1 2.2 3.3 RAPID 3 (0-30) Deal with feelings of anxiety or being nervous? 0 1.1 2.2 3.3 Deal with feelings of depression or feeling blue? 0 1.1 2.2 3.3 Cat: 2. How much pain have you had because of your condition Please indicate below how severe your pain has been: OVER THE PAST WEEK? NO PAIN AS BAD AS PAIN 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 IT COULD BE 3. Please place a check ( ) in the appropriate spot to indicate the amount of pain you are having today in each of the joint areas listed below: HS= MS= LS=3.1-6 LEFT FINGERS 0 1 2 3 RIGHT FINGERS 0 1 2 3 LEFT WRIST 0 1 2 3 RIGHT WRIST 0 1 2 3 LEFT ELBOW 0 1 2 3 RIGHT ELBOW 0 1 2 3 LEFT SHOULDER 0 1 2 3 RIGHT SHOULDER 0 1 2 3 LEFT HIP 0 1 2 3 RIGHT HIP 0 1 2 3 LEFT KNEE 0 1 2 3 RIGHT KNEE 0 1 2 3 LEFT ANKLE 0 1 2 3 RIGHT ANKLE 0 1 2 3 LEFT TOES 0 1 2 3 RIGHT TOES 0 1 2 3 NECK 0 1 2 3 BACK 0 1 2 3 4. Considering all the ways in which illness and health conditions may affect you at this time, please indicate below how you are doing: VERY VERY WELL 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 POORLY When you awakened in the morning OVER THE LAST WEEK, did you feel stiff? Yes No If Yes, please indicate the number of minutes or hours until you are as limber as you will be for the day How do you feel TODAY compared to ONE WEEK AGO? Please check only one Much better Better the Same Worse Much Worse How much of a problem has UNUSUAL fatigue or tiredness been for you OVER THE PAST WEEK? Fatigue is no problem Fatigue is a major problem 1 2 3 4 5 6 7 8 9 10 FOR Office Use Only: I have reviewed the questionnaire responses. Date: Signature: >12 6.1-12 R=<3

Please list all major illnesses or hospital admissions (other than for operations): Year Reason Hospital Please list all operations that you have ever had: Year Reason Hospital Please check mark if you have had any of the conditions listed below: Head/Eye/Ear/Nose/Throat Gastrointestinal Musculoskeletal Dry eyes Stomach ulcer Back or spine problems Cataracts Other gastrointestinal problem Osteoarthritis Dry mouth Genitourinary Rheumatoid arthritis Cardiovascular Kidney problem Lupus High blood pressure Gynecological (female) problem ibromyalgia Heart attack Prostate (male) problem Broken bones after age 50 Palpitations Endocrine Osteoporosis Other heart disease Diabetes Skin Respiratory Thyroid disorder Psoriasis Asthma Hematologic Other skin disease Severe allergies Problems with blood clotting Psychiatric Emphysema Cancer Depression Bronchitis Neurologic Alcoholism history of tuberculosis Stroke ental illness Other respiratory disease Parkinson s disease Other: MEDICATION HISTORY LIST YOUR PRESCRIBED DRUGS Name the Drug Strength Frequency Taken OVER THE COUNTER MEDICATIONS Name the Drug Strength Frequency Taken

ALLERGIES TO MEDICATIONS Name the Drug Reaction You Had FAMILY HEALTH HISTORY AGE SIGNIFICANT HEALTH PROBLEMS AGE SIGNIFICANT HEALTH PROBLEMS Father Mother Sibling Children Grandmother Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal SOCIAL HISTORY HABITS: Tobacco Do you use tobacco? Yes No Cigarettes pks./day Chew - #/day Pipe - #/day Cigars - #/day # of years Or year quit Alcohol Do you drink alcohol? Yes No Drugs Do you currently use recreational or street drugs? Yes No Occupation What is your current occupation? If retired, what was your past occupation? Exercise Sedentary (No exercise) ild exercise (i.e., climb stairs, walk 3 blocks, golf) Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.) Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes) Caffeine None Coffee Tea Cola # of cups/cans per day? Personal Safety Do you live alone? Yes No Do you have frequent falls? Yes No Do you have vision or hearing loss? Yes No Have you ever had a fracture (broken bone)? Yes No Females Only Bone Density Have you gone thru menopause? If YES, at what age? Have you had a bone density test done? If YES, when and where was this done? Yes No Yes No

PATIENT/GUARDIAN STATEMENT: PROVIDER STATEMENT: To the best of my knowledge, the above information Is accurate and complete I have reviewed the questionnaire with the patient Any Changes / / Patient Signature Date Signed Date / / Guardian Signature Date Signed Date Guardian/Authorized Representative Printed Name Signed Date Signed Date

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