Greensboro Medical Associates Rheumatology New Patient Form
Please complete all sections. This form collects your medical, surgical, family, and social history to assist with your rheumatology care.
Patient Information
Name
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Primary Care Physician
*
Referring Physician
Describe briefly your symptoms
*
Pharmacy
Medications (Drug Name, Dose and How Often You Take)
Medical History (Medical Diagnosis and year Diagnosed)
Allergies (Medications + Reaction, Foods/Other + Reaction)
Surgical History (Surgery, Year, Doctor)
Family History of Medical Conditions
Mother
Father
Brother(s)
Sister(s)
Son(s)
Daughter(s)
Other Family with Rheumatic Condition
Social History
Occupation
Marital Status
Please Select
Single
Married
Divorced
Widowed
Children
Please Select
Yes
No
If Yes, How Many Children
Do you smoke?
Please Select
Yes
No
Previous
Packs per day
For how long (smoking)?
Year Quit (smoking)
Do you use illicit drugs?
Please Select
Yes
No
Do you consume alcohol?
Please Select
Yes
No
If yes, how often (alcohol)?
Do you exercise?
Please Select
Yes
No
How often (exercise)?
If You Have Never Had a Tuberculosis Test, Leave Blank
Date of last Tuberculosis test
-
Month
-
Day
Year
Date
Result of last Tuberculosis test
Review of Symptoms
Check All That Apply
General
Fatigue
Fever
Headache
Weight gain
Weight Loss
Hives
Itching
Decreased Vision
Dry Eyes
Mouth Sores
Dry Mouth
Cold Intolerance
Weakness
Shortness of Breath
Cough
Chest Pain
Dizziness
Fluid Accumulation in The Legs
Irregular Heartbeat
Abdominal Pain
Constipation
Nausea/Vomiting
Easy Bruising
Blood In Urine
Difficulity Urinating
Joint Stiffness
Muscle Aches
Painful Joints
Swollen Joints
Hair Loss
Rash
Sun Sensitivity
Tingling/Numbness
Color Changes In Hands or Feet In The Cold
Loss of Strength
Anziety
Depressed Mood
Other
If Other, Please List
I certify that the information I have given above is correct to the best of my knowledge.
Patient’s Signature
*
Date
*
-
Month
-
Day
Year
Date
If Not Patient Filing Out The Form
Signature Of Person Filling Out Form
Relationship To Patient
Submit
Submit
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