Microsoft word - patient medical history rheumatology

Date of Appointment: WMG Account Number:
PERSONAL AND SOCIAL HISTORY

Do you live alone?
Education: Do you regularly consume alcohol? Average number of drinks per week (now or in the past)? How would you describe your cigarette smoking? How many packs per day do you (or did you) smoke? Does anybody smoke in the house in which you live? How many caffeinated beverages do you consume per day? IV drug use or other recreational drug use? Have you engaged in high risk behavior for sexually transmitted diseases (anal sex, multiple sex partners, same sex)? Never Have you recently traveled outside of the US? Do you have any Body Piercings/ Tattoos? How much weight change have you experienced? PATIENT MEDICAL HISTORY
ALLERGIES:
MEDICATION ALLERGIES:
Please list the all allergies that have given you reactions. Please list the all medications that have given you If possible, include your reactions (hives, welts, rash, itching, headaches, nausea, diarrhea, passed out, shock, shortness of breath). If possible, include your reactions (hives, welts, rash, itching, headaches, nausea, diarrhea, passed out, shock, shortness of breath). INJURIES
What PRESCRIPTION medications are you taking at
this time? (Alternatively bring in an accurate list with you) IMMUNIZATIONS
What OVER-THE-COUNTER medications are you
taking? (e.g. aspirin, Motrin, Tagament-HB, vitamins, etc.) FOR WOMEN ONLY
PATIENT MEDICAL HISTORY CONTINUED
SURGERIES (Please mark all surgeries you have had)

Hysterectomy (Indicate type of Hysterectomy: Total or Partial / Abdominal or Vaginal) …
OTHER CONDITIONS

Abnormal Heartbeat/ Palpitations … Osteoporosis Diabetes (Circle: Type I/Type II) … Thyroid Hepatitis (Circle: Type B/Type C) … Depression FAMILY HISTORY

Age at Death
Cause of Death

Please list all family members effected by the following:
Family History Unknown … Adopted … M = Mother MGM = Maternal Grandmother MGF = Maternal Grandfather F = Father
PGM = Paternal Grandmother PGF = Paternal Grandfather B = Brother S = Sister O = Other immediate family
RHEUMATIC DISEASE EVALUATION

Briefly describe your present symptoms:
When did you first notice your symptoms? Do you become unusually fatigued during the day? Does sunlight bother you or cause a rash? Have you had any hair loss with these symptoms? Do your hands turn blue/ white in cold weather? Please list the joints that have been involved: List physicians, podiatrists, or chiropractors you have seen for arthritis and the approximate date of these evaluations: Have you taken any of the following drugs? • Check the following code boxes accordingly Analgesics – NSAIDs
Disease Modifiers (DMARDS)
Corticosteroids
Other Rheumatologics
hydroxychloroquine Osteoporosis/ Osteopenia
Biologics
Hormones
Analgesics – Narcotics
Muscle Relaxants
Other Neurologics
Sjögren’s Syndrome
Antidepressants
Analgesics - Other
Anti-Parkinsonians
Anti-convulsants
Immunosuppressants

FUNCTIONAL EVALUATION:
MODIFIED HEALTH ASSESSMENT QUESTIONAIRE (mHAQ)
Formula: Total score = number of answered questions = mHAQ

Please mark the one response that best describes your usual abilities
1) Dress yourself, including tying shoelaces and fastening buttons? 6) Bend down and pick up clothing from the floor? On a scale of 1-10, how would you rate your PAIN? None |-----|-----|-----|-----|-----|-----|-----|-----|-----|-----| Severe On a scale of 1-10, how would you rate your FATIGUE? None |-----|-----|-----|-----|-----|-----|-----|-----|-----|-----| Severe On a scale of 1-10, how would you rate your DISEASE ACTIVITY? None |-----|-----|-----|-----|-----|-----|-----|-----|-----|-----| Severe
Circle either YES or NO
PLEASE DO NOT WRITE IN SPACE BELOW
Have you ever had a convulsion, fit, or epilepsy? Have you had a rash or other skin problems? Have you had pain or ringing in your ears? Have you ever had chest pain or tightness in your chest? Have you had a heart attack? (In what year(s):_____________________) Have you had any recent changes in your bowel habits? Have you ever had an ulcer? (In what year(s):______________________) Have you had intestinal bleeding, black, or tarry stools? Have you had recent frequency or burning with urination? Do you get up frequently at night to urinate? (How many times? _______) Have you ever passed a kidney stone? (In what year(s):______________) Are you more sensitive to cold exposure than others in the same area? Have you been nervous or depressed? (circle if applicable) Has there been a change in frequency or amount of your menstrual flow? Date of last period? ____________________ Date of last pap smear (cancer test)? ____________________ Date of last DEXA or Osteoporosis screening? ____________________ Number of pregnancies? ____________________ Number of children born alive? ____________________

Source: http://www.wmgmed.com/post/forms/Patient%20Medical%20History%20Rheumatology.pdf