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New Patient History Form Today s Date: MICHAEL L. MAWBY, MD MARIANNE PEACOCK, CNP 1115 S. Union Street Traverse City, MI 49684 Form Revised 1/18/2016 Name: Birthdate: (Last) (First) (MI) (Maiden) (MM/DD/YYYY) Address: Age: Sex: F M Street Apt# City State Zip MARITAL STATUS: Never Married Married Divorced Separated Widowed Spouse/Significant Name 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 Employer Referred here by: (check one) Self Family Friend Doctor Other Health Professional Name of person making referral: Primary Care Physician: Are you on disability? Y N Applying/or planning to apply for disability? Y N Are you currently or have you been involved in a medically related lawsuit? Y N Describe briefly your present symptoms: Date symptoms began (approximate): Diagnosis: 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: RHEUMATOLOGIC (ARTHRITIS) HISTORY At any time have you or a blood relative had any of the following? (Check if yes ) Yourself Relative/Relationship Yourself Relative/Relationship Arthritis (unknown type) Lupus or SLE Osteoarthritis Rheumatoid Arthritis Gout Ankylosing Spondylitis Childhood arthritis Osteoporosis Other arthritis conditions: Revised 1/18/2016 Page 1 of 5

SYSTEM REVIEW Date of last chest x-ray Date of last Tuberculosis Test Date of last bone densitometry As you review the following list, please check any of these problems which have significantly affected you. Constitutional Gastrointestinal Skin Fatigue Stomach pain Hives Fever Difficulty swallowing Rash Chills Vomiting of blood or coffee ground material Sun sensitive (sun allergy) Night Sweats Blood in stools Psoriasis Hot flashes Black stools Nodules Recent weight loss amount Constipation Tightness/thickening Recent weight gain amount Persistent diarrhea Heartburn Musculoskeletal Eyes-Ears-Nose-Mouth-Throat Reflux Back pain Dry eyes Nausea Neck pain Itchy eyes Decreased appetite Joint pain Eye pain Joint swelling Eye Inflammation Genitourinary Muscle pain Vision changes Cloudy, "smoky" urine Muscle tenderness Blurred vision Double vision Pain or burning on urination Blood in urine Muscle weakness Morning stiffness lasting how long? Dry mouth Getting up at night to pass urine mins hours Mouth sores Rash/ulcers List joints affected in the last 6 months Mouth ulcers Abnormal discharge from penis/vagina Excessive dental decay Hoarseness For Women Only: Any previous fractures? Y N Sinus Problems Periods regular? Y N Which bone/cause of fracture: Runny nose Date of last period? Parotid Swelling Number of pregnancies? Hearing loss Number of miscarriages? Height loss Ringing in ears What was the tallest height you have ever Neurological System been? FT IN Respiratory Dizziness Any other serious injuries? Y N Chronic cough Lightheadedness Please describe: Cough Vertigo Shortness of breath at rest Numbness Shortness of breath with activity Tingling Difficulty breathing at night Headaches Hemotologic/Lymphatic Pleurisy Jaw cramping when chewing Easy bruising Coughing up blood Scalp tenderness Easy bleeding Wheezing (asthma) Memory Loss Blood clots Seizures Anemia Cardiovascular Swollen glands Chest pain Chest pressure Psychiatric Swollen legs or feet (edema) Anxiety Irregular heart beat Depression Allergic/Immunologic Heart palpitations Suicidal thoughts Frequent sneezing Color chgs of hands or feet in cold Difficulty falling asleep Environmental allergies Difficulty staying asleep Food allergies Endocrine Wake up tired in morning Seasonal allergies Excessive hair loss Frequent infections Male pattern hair loss Recent infection Excessive thirst Revised 1/18/2016 Page 2 of 5

Social History Past Medical History Do you now or have you ever had: (check if yes ) Do you drink caffeinated beverages? Y N Cancer Heart Problems Asthma Cups/glasses per day? Thyroid Problems Leukemia Stroke Do you smoke? Y N Previous smoker? Y N Cataracts Diabetes Epilepsy/Seizures When did you stop? Nervous breakdown Stomach ulcers Rheumatic fever Do you drink alcohol? Y N Number per week Migraine Jaundice Colitis Has anyone ever told you to cut down on your drinking? Kidney disease Pneumonia Psoriasis Y N Kidney stones HIV/AIDS High Blood Pressure Do you use drugs for reasons that are not medical? Anemia Glaucoma Tuberculosis Y N Emphysema Irritable Bowel Syndrome If yes, please list Heart Murmur Prostate problems Other significant illness (please list) Do you exercise regularly? Y N Type Amount per week How many hours of sleep do you get at night? Do you get enough sleep at night? Y N Do you wake up feeling rested? Y N Natural or Alternative Therapies (chiropractic,magnets,massage,over the counter preparations, etc.) Previous Operations Type Year Reason 1. 2. 3. 4. 5. Family History IF LIVING IF DECEASED Age Health Age at Death Cause of Death Father Mother Number of siblings Number living Number deceased Number of children Number living Number deceased List ages of each Health of children: Do you know of any blood relative who has or had: (check and give relationship) Cancer Heart Disease Epilepsy Leukemia High Blood Pressure Asthma Stroke Bleeding Tendency Psoriasis Colitis Alcoholism Thyroid Disease Tuberculosis Diabetes Revised 1/18/2016 Page 3 of 5

MEDICATIONS Drug allergies: Y N To what? Type of reaction: PRESENT MEDICATIONS (List any medications you are taking. Include such items as aspirin, vitamins, laxative, calcium and other supplements, etc) Dose (Include strength & How long have you Name of Drug number of pills per day) taken this medication? A Lot Some Not At All 1. 2. 3. 4. 5. 6. 7. 8. 9. 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 comment in the spaces provided. Drug names/dosage Pain Relievers Acetaminophen (Tylenol) Codeine(Vicodin, Tylenol 3) Ultram(Tramadol/ultracet) Disease Modifying Antirheumatic Drugs (DMARDS) Ridaura (Auranofin, gold pills) Gold shots (Myochrysine or Solganol) Plaquenil (Hydroxychloroquine) Penicillamine (Cuprimine or Depen) Methotrexate (Rheumatrex) Imuran (Azathioprine) Sulfasalazine (Azulfidine) Arava (Leflunomide) Cytoxan (Cyclophosphamide) Cyclosporine A (Sandimmune or Neoral) Enbrel (Etanercept) Remicade (Infliximab) Humira (Adalimumab) Simponi (Golimumab) Cimzia (Certolizumab) Orencia (Abatacept) Actemra (Tocilizumab) Rituxan (Rituximab) Length of time A Lot Some Not At All Reactions Revised 1/18/2016 Page 4 of 5

PAST MEDICATIONS Continued Drug names/dosage Osteoporosis Medications Estrogen (Premarin, etc.) Fosamax (Alendronate) Actonel (Risedronate) Forteo (Teriparatide) Evista (Raloxifene) Calcitonin injections or nasal (Miacalcin, Calcimar) Boniva (Ibandronate) Reclast (Zoledronic Acid) Prolia (Denosumab) Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) Ansaid (flurbiprofen) Arthrotec (diclofenac + misoprostol) Aspirin (including coated aspirin) Celebrex (celecoxib) Daypro (oxaprozin) Disalcid (salsalate) Dolobid (diflunisal) Feldene (piroxicam) Indocin (indomethacin) Lodine (etodolac) Mobic (Meloxicam) Motrin/Rufen (ibuprofen) Naprosyn (naproxen) Oruvail (ketoprofen) Relafen (nabumetone) Tolectin (tolmetin) Vimovo (Naproxen + esomeprazole) Voltaren (diclofenac) Gout Medications Probenecid (Benemid) Colchicine Allopurinol (Zyloprim/Lopurin) Febuxostat (Uloric) Others Tamoxifen (Nolvadex) Cortisone/Prednisone/Medrol Hyalgan/Synvisc/Supartz/Euflexxa injections Herbal or Nutritional Supplements Please list supplements: Length of time A Lot Some Not At All Reactions All 5 pages completed by: Relationship: Patient Spouse Parent Other Print Name Signature Revised 1/18/2016 Page 5 of 5 Date:

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