Patient History Form pdf - American College of Rheumatology

American College of Rheumatology

Patient History Form

Date of first appointment:

Time of appointment:

Birthplace:

Name:

Last

First

Maiden

Birthdate:

Age:

Sex: Male Female

Home Phone:

Work Phone:

Cell Phone:

Address:

Marital Status: Never Married Married

Divorced

Separated Widowed

Spouse/Significant Other:

Alive/Age ___ Deceased/Age Major Illnesses __________

Education: (check (

√) highest level attended)

Grade School: 7

10 11 12

College:

Graduate School:

Occupation:

Number of hours worked/average per week: _______

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:

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:

Please place an "X" on all the locations of your pain over the past week by clicking on the appropriate areas on

the body figures and hands below:

Please review the following list.

Please check any of those problems which have significantly affected you.

Constitutional

Recent weight gain
Amount ________

Recent weight loss
Amount ________

Fatigue

Weakness

Fever

Eyes

Pain

Redness

Loss of vision

Double or blurred vision

Dryness

Feels like something in eye

Itching eyes

Ears-Nose-Mouth-Throat

Ringing in ears

Loss of hearing

Nosebleeds

Loss of smell

Dryness in nose

Runny nose

Sore tongue

Bleeding gums

Sores in mouth

Loss of taste

Dryness of mouth

Frequent sore throats

Hoarseness

Difficulty in swallowing

Cardiovascular

Pain in chest

Irregular heart beat

Sudden changes in heart
beat

High blood pressure

Heart murmurs

Respiratory

Shortness of breath

Difficulty in breathing at
night

Swollen legs or feet

Cough

Coughing of blood

Wheezing (asthma)

Gastrointestinal

Nausea

Vomiting of blood or coffee
ground material

Stomach pain relieved by
food or milk

Jaundice

Increasing constipation

Persistent diarrhea

Blood in stools

Black stools

Heart burn

Genitourinary

Difficult urination

Pain or burning on
urination

Blood in urine

Cloudy “smoky” urine

Pus in urine

Discharge from
penis/vagina

Getting up at night to pass
urine

Vaginal dryness

Rash/ulcers

Sexual difficulties

Prostate trouble

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:  ________

Musculoskeletal

Morning stiffness
Lasting how long?
_____ minutes
_____ hours

Joint Pain

Muscle weakness

Muscle tenderness

Joint swelling

Musculoskeletal cont.:
List joints affected in the last six
months: _____________________
_____________________________
_____________________________
_____________________________
Integumentary (skin and/or breasts)

Easy bruising

Redness

Rash

Hives

Sun sensitive (sun allergy)

Tightness

Nodules/bumps

Hair loss

Color changes of hands or
feet in the cold

Neurological System

Headaches

Dizziness

Fainting

Muscle spasm

Loss of consciousness

Sensitivity or pain of hands
and/or feet

Memory loss

Night sweats

Psychiatric

Excessive worries

Anxiety

Easily losing temper

Depression

Agitation

Difficulty falling asleep

Difficulty staying asleep

Endocrine

Excessive thirst

Hematologic/Lymphatic

Swollen glands

Tender glands

Anemia

Bleeding tendency

Transfusion/when _______

Allergic/Immunologic

Frequent sneezing

Increased susceptibility to
infection

Rheumatologic (ARTHRITIS) History

At any time have you or a blood relative had any of the following (check (

√) if yes)

Yourself

Relative

Name/Relationship

Yourself

Relative

Name/Relationship

Arthritis
(unknown
type)

Lupus or
“SLE”

Osteoarthritis

Rheumatoid
Arthritis

Gout

Ankylosing
Spondylitis

Childhood
arthritis

Osteoporosis

Other arthritis conditions:

Date of last mammogram:

Date of last eye exam:

Date of last chest x-ray:

Date of last Tuberculosis Test:

Date of last bone densitometry:

Social History

Do you drink caffeinated beverages? Yes No

If yes, cups/glasses per day? _________________

Do your smoke? Yes No Past-How long ago? ________

Do you drink alcohol? Yes No Number per week __________

Has anyone ever told you to cut down on your drinking? Yes No

Do you use drugs for reasons that are not medical? Yes No

If yes, please list: ______________________________________________________________________

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

Past Medical History

Do you now or have you ever had (check if yes)

Cancer

Goiter

Cataracts

Nervous Breakdown

Bad headaches

Kidney disease

Anemia

Emphysema

Heart problems

Leukemia

Diabetes

Stomach ulcers

Jaundice

Pneumonia

HIV/AIDS

Glaucoma

Asthma

Stroke

Epilepsy

Rheumatic Fever

Colitis

Psoriasis

High Blood Pressure

Tuberculosis

Other significant illness (please list)

Natural or Alternative Therapies (chiropractic, magnets, massage, over the counter preparations, etc.):

Previous Operations

Types

Year

Reason

Any previous factures? Yes No

Describe:

Any other serious injury? Yes No

Describe:

Family History

If Living

If Deceased

Age

Health

Age at Death

Cause

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 had (check and give relationship)

Cancer

Leukemia

Stroke

Colitis

Heart Disease

High blood pressure

Bleeding tendency

Alcoholism

Rheumatic Fever

Epilepsy

Asthma

Psoriasis

Tuberculosis

Diabetes

Goiter

Medications

Drug allergies

Yes No

To what? ____________________________________________________________________________
____________________________________________________________________________________

Type of reaction? ______________________________________________________________

Present Medications

(List any medications you are taking, include 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

taken this

medication

Please check: Helped?

A lot Some Not at all

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

Length of

Time

Please check: Helped?

A lot Some Not at all

Reactions

Non-Steroidal

Anti-inflammatory Drugs

(NSAIDs)

Check any you have taken in the past

Ansaid (flurbiprofen)

Arthrotec (diclofenac + misoprostil)

Aspirin (including coated aspirin)

Celebrex (celecoxib)

Clinoril (sunlindac)

Daypro (oxaprozin)

Disalcid (salsalate)

Dolobid (diflunisal)

Feldene (piroxicam)

Indocin (indomethacin)

Lodine (etodolac)

Meclomen (Meclofenamate)

Motrin/Rufen (ibuprofen)

Nalfon (fenoprofen)

Naprosyn (naproxen)

Oruveil (ketoprofen)

Tolectin (tolmetin)

Trillsate (chollne magnesium trisalicylate)

Vioxx (rofecoxib)

Voltaren (diclofenac)

Pain Relievers

Length of

Time

Please check: Helped?

A lot Some Not at all

Reactions

Acetaminophen (Tylenol)

Codeine (Vicodin, Tylenol 3)

Propoxyphene

(Darvon/Darvocet)

Other:

Disease Modifying

Antirheumatic Drugs

(DMARDS)

Auranofin, gold pills

(Ridaura)

Gold shots (Myochrysine or

Solganol)

Hydroxycholoroquine

(Plaquenil)

Disease Modifying

Antirheumatic Drugs

(DMARDS)

Length of

Time

Please check: Helped?

A lot Some Not at all

Reactions

Penicillamine (Cuprimine or

Depen)

Methotrexate

(Rheumatrex)

Azathioprine (Imuran)

Sulfasalazine (Azulfidine)

Quinacrine (Atabrine)

Cyclophosphamide

(Cytoxan)

Cyclosporine (Sandimmune

or Neoral)

Etanercept (Enbrel)

Infliximab (Remicade)

Prosorba Column

Other

Osteoporosis Medications

Estrogen (Premarin, etc.)

Alendronate (Fosamax)

Etidronate (Didronel)

Raloxifene (Evista)

Fluoride

Calcitonin injection or nasal

(Miacalcin, Calcimar)

Risedronate (Actonel)

Other

Gout Medications

Probenecid (Benemid)

Colchicine

Allopurinol

Gout Medications

Length of

Time

Please check: Helped?

A lot Some Not at all

Reactions

(Zyloprim/Lopurin)

Other

Others

Tamoxifen (Nolvadex)

Tiludronate (Skeklid)

Cortisone/Prednisone

Hyalgan/Synvisc injections

Herbal or Nutritional

Supplements

Please list supplements:

Have you participated in any clinical trials for new medications? Yes No

If yes, please list:

Activities of Daily Living

Do you have stairs to climb?                            Yes         No             If yes, how many?  _________________
How many people in household?  _____
Relationship and age of each ____________________________________________________________
Who does the most housework?  _________________ Who does most of the shopping? ____________
Who does most of the yard work? ________________

On the scale below, check the box which best describes your situation: Most of the time, I function….

Very poorly Poorly Ok Well Very well

Because of health problems, do you have difficulty:

(Please check the appropriate response for each question.)

Usually

Sometimes

Using your hands to grasp small objects? (buttons,

toothbrush, pencil, etc.)

Walking?

Climbing stairs?

Descending stairs?

Sitting down?

Getting up from chair?

Touching your feet while seated?

Reaching behind your back?

Reaching behind your head?

Dressing yourself?

Going to sleep?

Staying asleep due to pain?

Obtaining restful sleep?

Bathing?

Eating?

Working?

Getting along with family members?

In your sexual relationship?

Engaging in leisure time activities?

With morning stiffness?

Do you use a: cane crutches
walker wheelchair

What is the hardest thing for you to do?

Are you receiving disability? Yes No

Are you applying for disability? Yes No

Do you have a medically related lawsuit pending? Yes No