Post on 03-May-2018
POLICIES/Rheumatology Patient Health History/01-04-16/423.9 Copyright 2016 Gulf Coast Medical Center 1
Rheumatology Patient History Form
Name: Birthdate: / / LAST FIRST MIDDLE INITIAL MAIDEN MONTH DAY YEAR
Address: Age: Sex: F M STREET APT#
Telephone: Home ( ) CITY STATE ZIP
Work ( )
Cell ( ) __________________
MARITAL STATUS: Never Married Married Divorced Separated Widowed
Spouse/Significant Other: Alive/Age Deceased/Age 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
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:
Example:
Please shade all the locations of your pain over the past week on the body figures and hands.
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
Adapted from CLINHAQ, Wolfe F and Pincus T. Current Comment – Listening to the patient – A practical guide to self report questionnaires in clinical care. Arthritis Rheum. 1999;42 (9):1797- 808. Used by permission.
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 Scleroderma
Rheumatoid Arthritis CREST Syndrome
Ankylosing Spondylitis Sjogren’s Syndrome
Psoriatic Arthritis Gout
Reactive Arthritis Osteoporosis
Childhood arthritis or JIA Fibromyalgia Syndrome
Other arthritis conditions:
Gulf CoastMedical Center
POLICIES/Rheumatology Patient Health History/01-04-16/423.9 Copyright 2016 Gulf Coast Medical Center 2
SOCIAL HISTORY Do you smoke? Yes No PastHow long ago?
Do you drink alcohol? No YesN umber per week
Has anyone ever told you to cut down on your drinking? Yes No
Do you drink caffeine? No YesN umber per week
Do you use any non-prescription drugs? Yes No If yes, please list: __________________________________________________
__________________________________________
Date of last eye exam / /
Date of last Tuberculosis Test / /
Date of last bone densitometry / /
How many hours of sleep do you get at night? ____ Have you fallen any time during the past year? Yes No If yes, how many falls? ______ When? _____ Injury? ___________________________________ Do you exercise? ____No ____ Minimal ____ Moderate Do you wake up feeling rested? Yes No Do you get enough sleep at night? Yes No Have you been told you snore? Yes No
PAST MEDICAL HISTORY
Do you now or have you ever had: (check if “yes”)
High Blood Pressure Heart Attack Glaucoma
Thyroid Disease Heart Failure Cataracts
Diabetes Stroke Macular Degeneration
Multiple Sclerosis Stomach ulcers Crohn’s Disease
Migraine Headaches Jaundice Ulcerative Colitis
Kidney disease Pneumonia Psoriasis
Asthma HIV/AIDS Tuberculosis
Emphysema / COPD Anemia Cancer________
Blood Transfusion ________________
Other significant illnesses (please list) __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________
History of sexually transmitted diseases? Yes No
Do you practice safe sex? _____________________
Occupation: __________________________________
Heavy Lifting Stress Repetitive Motion
Previous Operations
Type Year Reason
1.
2.
3.
4.
5.
6.
7.
Any previous fractures? No Yes Describe:
Any other serious injuries? No Yes Describe:
FAMILY HISTORY
Age
IF LIVIN
G
Health
Age at Death
IF DECEASED
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 or had: (check and give relationship):
Psoriasis
Gout
Crohn’s
Colitis
Tuberculosis
Diabetes
Thyroid Disease
Lupus
Rheumatoid Arthritis
Advance Directive Yes No Name: _____________________________________________ Relationship: _______________________
POLICIES/Rheumatology Patient Health History/01-04-16/423.9 Copyright 2016 Gulf Coast Medical Center 3
MEDICATIONS
Drug allergies: No Yes What drug and 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 you taken this
medication
Please check: Helped?
A Lot Some Not At All
1. 2.
3.
4.
5.
6.
7. 8.
9.
10.
11.
12.
13.
14.
15.
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.
Circle any of the following NSAIDs you have taken in the past
Ansaid (flurbiprofen) Arthrotec (diclofenac + misoprostil) Cataflam/Zipsor (diclofenac potassium Celebrex (celecoxib) Clinoril (sulindac)
Daypro (oxaprozin) Disalcid (salsalate) Dolobid (diflunisal) Feldene (piroxicam) Indocin (indomethacin) Lodine (etodolac)
Mobic (meloxicam) Motrin/Advil (ibuprofen) Nalfon (fenoprofen) Naprelan/Naprosyn (naproxen) Relafen (nabumetome)
Tolectin (tolmetin) Trilisate (choline magnesium trisalicylate) Voltaren (diclofenac) Vimovo (naproxen/esmoprazole)
Drug names/Dosage Length of time
Please check: Helped? A Lot Some Not At All
Reactions
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Pain Relievers
Ultram (Tramadol) Hydrocodone (Vicodin, Lortab, Norco) Oxycodone (Percocet, Endocet, Roxicet) Other:
Disease Modifying Antirheumatic Drugs (DMARDS)
Auranofin, gold pills (Ridaura) Gold shots (Myochrysine or Solganol) Azathioprine (Imuran) Cyclophosphamide (Cytoxan) Cyclosporine A (Sandimmune or Neoral) Hydroxychloroquine (Plaquenil) Leflunomide (Arava) Methotrexate (Rheumatrex) Penicillamine (Cuprimine) Sulfasalazine (Azulfidine)
POLICIES/Rheumatology Patient Health History/01-04-16/423.9 Copyright 2016 Gulf Coast Medical Center 4
Abatacept (Orencia) - Infusion Abatacept (Orencia) - Injection Adalimumab (Humira) Anakinra (Kineret) Certolizumab pegol (Cimzia) Etanercept (Enbrel) Golimumab (Simponi) Infliximab (Remicade) Rituximab (Rituxan) Tocilizumab (Actemra) Tofacitinib (Xeljanz) Other:
Osteoporosis Medications
Alendronate (Fosamax) Calcitonin injection or nasal (Miacalcin, Calcimar) Denosumab (Prolia) Estrogen (Premarin, etc.) Etidronate (Didronel) Ibandronate (Boniva) { circle oral or IV } Raloxifene (Evista) Risedronate (circle Actonel / Atelvia) Zoledronic Acid (Reclast) Other:
Gout Medications
Allopurinol (Zyloprim/Lopurin) Colchicine (Colcrys) Febuxostat (Uloric) Indomethacin (Indocin) Pegloticase (Krystexxa) Probenecid (Benemid) Other:
Others
Cortisone/Prednisone
Hyalgan/Synvisc/Othovisc/Supartz injections
Please list supplements below:
ACTIVITIES OF DAILY LIVING
Because of health problems, do you have difficulty: (Please check the appropriate response for each question.)
Usually Sometimes No
Using your hands to grasp small objects? (buttons, toothbrush, pencil, etc.)........................................................ Dressing yourself? ................................................................................................................................................ Bathing?...........................................................................................................................................................................
Eating?.............................................................................................................................................................................
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 lawsuits pending?.........................................................................................Yes No