May 5, 2019

History Form

About you:

Allergies

Are you allergic to any medication?
If yes, to what? What happened?
Food allergies
(i.e. peanut, egg, shellfish, etc.)

Present Symptoms:

Please describe your present symptoms (what brings you in today?)
Were you referred for an abnormal blood test result?
If so, what was the concern (check all that apply):
Positive ANA Elevated rheumatoid Factor ESR CRP
Do you have early morning joint stiffness?
Do you have pain?
Have you ever been seen by a rheumatologist?

About Your Symptoms

Do your symptoms:
When do you have your symptoms?
MorningAfternoonEveningNight
Most
Least
List your symptoms and dates when they began:
DateDate
Multiple miscarriages Hearing loss
Sinusitis Asthma
Hair loss (balding) Rash/psoriasis
Fetal death
Symptoms started: All of a sudden Gradually
Did you have any of the following prior to the onset of your symptoms?

Previous treatments for this problem:

Did you ever take corticosteroids?
Did you ever break a bone?

Pain

Please indicate the type of pain and location:
Side Aching Burning Stabbing Crampy Electric shock Pins and needles Pulling
RL
Fingers
Wrist
Elbow
Shoulder
Hip
Knee
Ankle
Toes
Neck
Mid Back
Low Back
Arm
Muscles
Leg Muscles
What affects your pain?
Rest Activity Medication Exercises Ice Heat Others
Better
Worse

Pertinent Symptoms

Please indicate if you experienced any of the below:
Blood clot, deep vein thrombosis or pulmonary embolism Fingers changing color in the cold or due to stress (white to blue to red)?
Dry mouth Glaucoma
Vaginal dryness Constipation
Itchy red skin on sun exposure Sores in nose or mouth
Muscle pain Numbness or tingling
Swollen lymph nodes or swollen glands Dry eyes
Chest pain Diarrhea
Shortness of breath Stroke
Family history of blood clot or stroke at a young age Abdominal pain, liver problems, or Hepatitis B/C
Kidney Failure Kidney Stones
Protein in the urine Diabetes
Thyroid condition Cataract
Miscarriages Blood clot in artery or vein or pulmonary embolism
Pain or burning on urination Urinary retention

Sleep

Do your symptoms disturb your sleep? Yes No
Do you get enough sleep at night? Yes No
Do you wake up feeling rested? Yes No
How many hours do you sleep per night? hours
Do you work the night shift or alternating day/night shifts? Yes No

Tests

Did you have any of the following done? If so, when?
DateDate
Chest X-Ray Colonoscopy
Mammogram Bone density test
Pelvic exam (women only) Skin biopsy
PSA (men only) Rectal exam
Colonoscopy Kidney biopsy

Vaccines

Pneumonia 13 23 valent Flu Pneumonia Shingles

Hospitalizations

ReasonYear

Surgeries

TypeReasonYear

Social History

Do you smoke? Never
Yes Packs per Day: For # Years:
Past Year Quit:
Do you exercise regularly? No Yes Amount / week:
Do you drink alcohol? No Yes # Drinks per day:
Did you ever use drugs for reasons that are not medical? Yes No
If yes, please list:

Marital Status

Never Married Married Divorced Separated Widowed
Spouse/Significant Other:
Alive/Age: Deceased/Age: Major Illness:

Education


Graduate School:

Family History

If Living If Deceased
Age Health Age at Death Cause
Father
Mother


Condition Who had it? Condition Who had it?
Rheumatoid Arthritis Psoriasis
Lupus Thyroid Disease
Crohn’s disease Ulcerative Colitis
Asthma Tuberculosis
Gout Blood clot in an artery of
vein or stroke at young age

Present Medications

Please list any medications you are taking, INCLUDING such items as aspirin, vitamins, laxatives, calcium, herbal supplements, etc.
1 7
2 8
3 9
4 10
5 11
6 12