Dr. Gina Del Giudice, M.D., FACR, FACP Michael J. Froncek, M.D., MS, FACP, FACR INITIAL PATIENT HISTORY AND HEALTH ASSESMENTS

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Dr. Gina Del Giudice, M.D., FACR, FACP Michael J. Froncek, M.D., MS, FACP, FACR INITIAL PATIENT HISTORY AND HEALTH ASSESMENTS Please take a few minutes to fill out the information on all six pages as completely as you can. Any information you can give on this form will help in our care for you; if you cannot fill out a section, please skip it and move on. Thank you. PERSONAL HISTORY: Marital Status: Minor Never Married Married Separated Divorced Widowed Spouse/Significate Other: Alive / Age: Deceased / Age: Major Illnesses: Education: Grade School 7 8 9 10 11 12 College 1 2 3 4 Graduate School Employment: F/T P/T Student Homemaker Retired Disabled Unemployed Other Occupation Number of Hours Worked / Average per Week Referred here by: Self Family Friend Doctor Other Health Professional Other Name of Referral Source: Name of your Primary Care Provider: Do You Have an Orthopedic Surgeon? Yes No If Yes, Name: SOCIAL HISTORY: Do you drink caffeinated beverages Yes No If Yes, Cups / Glasses per day: Do you smoke? Never Yes: Packs / Day: # Years: Past: How Long Ago? Do you drink alcohol? Yes: Number of Drinks per Week: No Has anyone ever told you to cut down on your drinking? Yes No Do you exercise regularly? Yes No Type: Amount per Week: How many hours of sleep do you get at night? Do you get enough sleep at night? Yes No Do you wake up feeling rested? Yes No FAMILY HISTORY: FATHER MOTHER IF LIVING IF DECEASED AGE HEALTH AGE AT DEATH CAUSE Number of siblings: Number Living: Number Deceased: Number of Children: Number Living: Number Deceased: List age / health of each child: Do you know of any blood relative who has or had.. (check and give relationship) Gout Epilepsy Tuberculosis Goiter Asthma Diabetes Stroke Psoriasis Leukemia Colitis Cancer Alcoholism

MEDICAL HISTORY: As you review the following list, please check any items which have significantly affected you. CONSTITUTIONAL EARS NOSE-MOUTH-THROAT CARDIOVASCULAR NEUROLOGICAL SYSTEM Recent weight gain Ringing in Ears Pain in chest Headaches Amount: Loss of hearing Irregular heart beat Dizziness Recent weight loss Nosebleeds Sudden changes in heat beat Fainting Amount: Loss of smell High blood pressure Muscle Spasm Fatigue Dryness in Nose Heart murmurs Loss of consciousness Weakness Runny Nose GASTROINTESTINAL Sensitivity or pain in hands/feet Fever Sore Tongue Nausea Memory loss SKIN AND /OR BREAST Bleeding Gums Vomiting of blood or coffee grounds Night sweats material Easy Bruising Sores in Mouth Stomach pain relieved by food or milk PSYCHIATRIC Redness Loss of Taste Jaundice Excessive worries Rash Dryness of mouth Increasing Constipation Anxiety Hives Frequent sore throats Persistent diarrhea Easily losing temper Sun Sensitivity (sun allergy) Hoarseness Blood in stools Depression Tightness Difficulty in swallowing Black stools Agitation Nodules / Bumps ENDOCRINE Heartburn Difficulty falling asleep Hair Loss Excessive thirst GENITOURINARY Difficulty staying asleep Color changes of hand or HEMATOLOGIC/LYMPHATIC Difficult urination MUSCULOSKELETAL feet in cold ALLERGIC /IMMUNOLOGIC Swollen glands Pain or burning on urination Morning stiffness Frequent sneezing Tender glands Blood in urine How long? Increased susceptibility to Anemia Cloudy, smoky urine JOINT PAIN infection EYES Bleeding tendency Pus in urine Muscle weakness Pain Transfusion Discharge from penis / vagina Joint swelling Redness When: Getting up at night to urinate List Joints Affected Loss of vision RESPIRATORY Vaginal dryness Double or blurred vision Shortness of breath Rash / Ulcers Dryness Difficulty in breathing at night Sexual difficulties Feels like something in eye Swollen legs or feet Prostate Trouble Itching eyes Cough Coughing of blood Wheezing (Asthma) FOR WOMEN ONLY Age when periods began: Periods regular? Yes No How many days apart: Date of last period: Date of last pap: Bleeding after menopause Yes No Number of pregnancies: Number of miscarriages: Contraceptive Method: PAST MEDICAL HISTORY: Do you now have, or have you ever had (Check if Yes) Anemia Diabetes High Blood Pressure Pneumonia Asthmas Emphysema HIV / AIDS Psoriasis Bad Headaches Epilepsy Jaundice Rheumatic Fever Cancer Glaucoma Kidney Disease Stomach Ulcers Cataracts Goiter Leukemia Stroke Colitis Heart Problems Nervous Breakdown Tuberculosis Other Significant Illnesses (Please List):

PAST SURGICAL HISTORY: Operations you have had: 1 2 3 4 5 TYPE Year Reason Any previous fractures? No Yes Describe: Any other serious injuries? No Yes Describe: Date of last Eye Exam: Date of last Bone Densitometry: Date of last Mammogram: Date of last Chest X-ray: Date of last Tuberculosis test: Date of last Pap Smear / PSA: MEDICATIONS: Please list any medications you are currently takin, INCLUDING such items as aspirin, vitamins, laxative, calcium, herbal supplement, etc. Name of Drug Dose (Include Strength & number of pills per day) How long have you taken this medication? Please Check: HELPED? 1 A lot Some No 2 A lot Some No 3 A lot Some No 4 A lot Some No 5 A lot Some No 6 A lot Some No 7 A lot Some No 8 A lot Some No 9 A lot Some No 10 A lot Some No Drug Allergies: NONE Yes To what? CURRENT MEDICAL HISTORY: Please describe briefly your present symptoms. (In other words, what brings you to us today?) About when did these symptoms begin?

CURRENT MEDICAL HISTORY (Continued) Have you been given a diagnosis for these symptoms? No Yes Have you been previously treated for this problem? No Yes What kind of treatment? Medication Physical Therapy Injection Surgery Other Please list the names of other practitioners you have seen for this problem: Please indicate all area you have had pain over the past week on the body figures and hands. XXXXX = PAIN............ = BURNING - - - - - - - - - - = TINGLING (Please indicate palms of hands on body) RHEUMATOLOGIC / ARTHRITIS HISTORY At any time, have you or a blood relative had any of the following? (Check if Yes ) Relationship Arthritis (unknown type) Self Relative Lupus or SLE Self Relative Osteoarthritis Self Relative Rheumatoid Arthritis Self Relative Gout Self Relative Ankylosing Spondylitis Self Relative Childhood Arthritis Self Relative Osteoporosis Self Relative Other Arthritis Self Relative Other Arthritis Self Relative Relationship 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. Drug Names / Dosage Length of Time Please Check: Helped? NSAIDS Ansaid (flurbiprofen) A lot Some No Arthrotec (Diclofenac&Misoprostol) A lot Some No Aspirin (Including coated aspirin) A lot Some No Celebrex (Celecoxib) A lot Some No Clinoril (Sulindac) A lot Some No Daypro (Oxaprozin) A lot Some No Disalcid (Salsalate) A lot Some No Dolobid (Diflunisal) A lot Some No Feldene (Piroxicam) A lot Some No Indocin (Indomethacin) A lot Some No Lodine (Etodolac) A lot Some No Meclomen (Meclofenamate) A lot Some No Motrin/Advil/Rufen (Ibuprofen) A lot Some No Reactions / Comments

Drug Names / Dosage Length of Time Please Check: Helped? NSAIDS (Continued) Oruvail/Orudis (Ketoprofen) A lot Some No Tolectin (Tolmetin) A lot Some No Trilisate (Choline Magnesium Trisallcylate) A lot Some No Vioxx (Rofecoxib) A lot Some No Voltaren (Difofenac) A lot Some No PAIN RELIEVERS Acetaminophen (Tylenol) A lot Some No Codeine (Vicodin, Tylenol #3) A lot Some No Propoxphene (Darvon/Darvocet) A lot Some No DISEASE MODIFYING ANTI-RHEUMATIC DRUG (DMARDs) Auranofin, Gold pill (Ridaura) A lot Some No Gold shots (Myochrysine or Golganol) A lot Some No Hydroxychloroquine (Plaquenil) A lot Some No Penicillamine (Cuprimine or Depen) A lot Some No Methotrexate (Rheumatrex) A lot Some No Azathioprine (Imuran) A lot Some No Sulfasalzine (Azulfidine) A lot Some No Quinacrine (Atabrine) A lot Some No Cycolophosphamide (Cytoxan) A lot Some No Cyclosporine A (Sandimmune or Neoral) A lot Some No Etanercept (Enbrel) A lot Some No Infiximab (Remicade) A lot Some No Prosorba Column A lot Some No OSTEOPOROSIS MEDICATIONS Estrogen (Premarin, etc.) A lot Some No Alendronate (Fosamax) A lot Some No Etidronate (Didronel) A lot Some No Raloxifene (Evista) A lot Some No Fluoride A lot Some No Calcitonim injection/nasal (Miacalin,Calcimar) A lot Some No Residronate (Actonel) A lot Some No GOUT MEDICATIONS Probenecid (Benemid) A lot Some No Colchicine A lot Some No Allopurinal (Zyloprim/Loqurin) A lot Some No OTHERS Tamoxifen (Nolvadex) A lot Some No Tiludronate (Skelid) A lot Some No Cortisone / Prednisone A lot Some No Hyalgan / Synvisc Injections A lot Some No HERBAL OR NUTRITIONAL SUPPLEMENTS Reactions / Comments Have you participated in any clinical trials for new medications No Yes If Yes, Please list:

Considering all the ways in which illness and health conditions may affect you At this time, please make a mark below to show how you are doing: Very Well I-------------------------------------------------------------------------------------------------------------I Very Poorly For Official Use Only GL How much pain have you had because of your condition over the past week? Place a mark on the line below to indicate how severe your pain has been: 0-100 No Pain I-------------------------------------------------------------------------------------------------------------I Pain as Bad as It Could Be PN Please answer the following questions, even if you feel that they may not be related to you at this time. Answer exactly as you think or fee there are no right or wrong answers. Check the one best answer for each question. ACITIVITY LEVEL Right now, are you able to: Without Any Difficulty With Some Difficulty With Much Difficulty Unable to Do 1 Dress yourself, including tying shoelaces and 0 1 2 3 doing buttons? 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. Walk two miles? 0 1 2 3 10. Participate in sports and games as you like? 0 1 2 3 FN SUBTOTALS (FOR OFFICE USE ONLY) 11. Get a good night sleep? 0 1.1 2.2 3.3 12. Deal with feelings of anxiety or being nervous? 0 1.1 2.2 3.3 13. Deal with feeling of depression or feeling blue? 0 1.1 2.2 3.3 PS Subtotals (FOR OFFICE USE ONLY) ADDITIONAL INFORMATION YOU WOULD LIKE TO DISCUSS DURING YOUR VISIT TODAY: 0-100 FN EQUALS 1 = 0.33 2 = 0.87 3 = 1.0 4 = 1.33 5 = 1.67 6 = 2.0 7 = 2.33 8 = 2.67 9 = 3.0 10 = 3.33 11 = 3.67 12 = 4.0 13 = 4.33 14 = 4.67 15 = 5.0 16 = 5 17 = 5 18 = 6 19 = 6 20 = 6 21 = 7 22 = 7 23 = 7 24 = 8 25 = 8 26 = 8 27 = 9 28 = 9 29 = 9 30 = 1

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