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