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

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Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information you provide us will greatly help us provide the highest quality and most comprehensive care for you. Please bring a current list of your medications, vitamins, and herbal supplements with you. Name: DOB: Age: Gender: M F Marital status: (circle one) Never married Married Divorced Separated Widowed Birthplace: Occupation: Hours worked/week: Education (circle highest level attended): 7 8 9 10 11 12 College: 1 2 3 4 Graduate School: Referred here by (circle one) Self Family Doctor Other (please specify): Your primary care provider: Name of person making referral: Do you have an orthopedic surgeon? If yes, who: Describe your present symptoms: Approximate date symptoms began: Previous treatment for these problems (include therapy, surgery, and injections) Shade all the locations of your pain over the past week on the body figures and hands

Medical History Do you have or have you ever had (check if yes ) Heart disease High blood pressure Asthma Colitis Epilepsy Migraine headaches Severe Pneumonia depression/anxiety Hepatitis C or B Stomach ulcers Kidney disease Emphysema Thyroid problems Diabetes High Psoriasis cholesterol/triglycerides Stroke Cancer HIV/AIDS TB Anemia Lymphoma Blood clots Gout Arthritis (unknown) LUPUS Osteoarthritis Rheumatoid Arthritis Ankylosing Spondylitis Childhood Arthritis Osteoporosis Obstructive sleep apnea Other significant illnesses (Please list) Hospitalizations, including surgeries: TYPE YEAR REASON 1. 2. 3. 4. 5. 6. 7. Any previous fractures? NO YES If yes, describe: Any other serious injuries? NO YES If yes, describe: Drug Allergies Do you have any drug allergies? NO YES If yes please list: Type of reaction: Do you have a reaction to Latex? YES NO Family History If living If deceased Age Health problems Age of death Cause of death Father: Mother: Number of siblings: Number living: Number deceased: Number of children: Number living: Number deceased: Health of children:

Do you know of any blood relatives who have or had (check and give relationship) High blood pressure: Lymphoma: Diabetes: Neurological disorder: Tuberculosis: Colitis: Bleeding disorder: Stroke: Asthma: Thyroid disease: Alcoholism: Psoriasis: Clotting disorder: Cancer: Gout: Arthritis (unknown) LUPUS or SLE: Osteoarthritis: Rheumatoid Arthritis: Ankylosing spondylitis: Childhood arthritis Osteoporosis: Social History Do you drink caffeinated beverages? NO YES if yes, how many cups per day Do you smoke? NO YES If yes, how long? How much? Pack(s) per Do you drink alcohol? NO YES If yes, how many drinks per week? Beer Wine Mixed drinks Has anyone ever told you to cut down on your drinking? NO YES Do you exercise regularly? NO YES If yes, amount per week: How many hours of sleep do you get at night? Do you get enough sleep at night? NO YES Do you wake feeling rested? NO YES Sleep medications: Are you receiving disability? NO YES Are you applying for disability? NO YES Do you have a medically related lawsuit pending? NO YES Female patients Do you have regular menstrual cycles? NO YES Age of menopause, if applicable How many pregnancies have you had? Births Miscarriages Are you pregnant now? NO YES If yes, how many weeks/months? Patient Assessment How much pain have you had because of your condition? Please make a mark below to show how you are doing Over the Past Week No Pain (0) Severe Pain (10) Considering the ways in which illness and health conditions may affect you at this point in time, please make a mark below to show how you are doing Over the Past Week Well (0) Severe (10) How much of a problem has fatigue or tiredness been for you Over the Past Week No Fatigue (0) Severe Fatigue (10)

Please check any of the symptoms that have been Significant Problems in the past 2 weeks Constitutional Cardiovascular Heme/Lymphatic, Cancer Fever Pain in chest Swollen or tender glands Fatigue Irregular heart beat Anemia Unexplained weight loss High blood pressure Bleeding tendency Integument/Skin Raynaud s Cancer: Easy bruising Swelling in the legs Endocrine Rash Gastrointestinal Diabetes Hives Nausea Elevated blood calcium Sun sensitivity Vomiting blood or coffee Elevated lipids ground material Nodules Heartburn/GERD Thyroid problems Hair loss Abdominal cramps/gas Low Vitamin D Eyes Constipation Osteoporosis/fractures Pain Diarrhea Psychiatric Redness Black or bloody stools Excessive worries Loss of vision Genitourinary Anxieties Double vision Pain/burning with urination Anger management issues Dryness Cloudy urine Depression Irritation in the eye Getting up at night to Agitation urinate Itching eyes Musculoskeletal Difficulty falling asleep Ears, Nose, & Throat Morning stiffness Difficulty staying asleep Ringing in the ears Joint pain Allergy/Immunology Loss of hearing Joint swelling Frequent sneezing Nosebleeds Muscle weakness Increased infections Sore tongue Muscle tenderness Infectious disease testing Sores in mouth Muscle spasms/cramps Last TB test: Loss of taste or smell Neurological Chest X-ray: Dryness of mouth Headaches Hepatitis B screen Hoarseness Tingling in arms or legs Hepatitis C screen Respiratory Loss of consciousness Shortness of Breath Carpal tunnel symptoms Cough Memory loss Coughing up blood Stroke like symptoms Wheezing (Asthma) Seizures Pleurisy Is there anything else I should know about for this visit? Signed: Date: MD: 9/18/14

Please list your CURRENT medications (including over the counter): MEDICATION: STRENGTH: DIRECTIONS ON BOTTLE: PRESCRIBING PHYSICIAN: Please list any other medications (including supplements) you have tried for your present symptoms: 9/18/14

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