Rheumatology Intake Form

Rheumatology Intake Form

Complete this patient intake form before your rheumatology appointment.
Appointment and Patient Information
Date of First Appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Appointment
Patient Name

First nameMiddle initialLast name
Email
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Birthplace
Age
Sex
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Marital Status
Spouse/Significant Other status
Age of living spouse or age at which spouse was deceased
Major illnesses of spouse
Highest education level attended
Grade school (years completed)
College (years completed)
Occupation
Average hours worked per week
Referral Source
Name of Person Making Referral

First NameLast Name
Primary Care Physician Name

First NameLast Name
Symptoms and Rheumatologic History
Briefly describe your present symptoms
Where have you had pain over the past week? Be specific as to side of body and limb.
For example, right ring finger, or left front shoulder.
Approximate date symptoms began
Diagnosis
Previous treatment for this problem
include PT, surgery and injections
At any time have you or a blood relative had any of the following?

At any time have you or a blood relative had any of the following?

Rows	Relative name/relationship	Yourself
Arthritis (unknown type)
Osteoarthritis
Gout
Childhood arthritis
Lupus or "SLE"
Rheumatoid arthritis
Ankylosing spondylitis
Osteoporosis

Other arthritis conditions
Screening and Systems Review
Fill in the date for screenings that apply. Simply skip the screenings that do not apply.

For the list below, please check any problems which have significantly affected you.
Date of last mammogram

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of last eye exam

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of last chest x-ray

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of last tuberculosis test

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of last bone densitometry

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Constitutional Symptoms
Amount of weight loss or gain
Eyes
Ears, nose, mouth and throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Integumentary (skin and/or breast)
Neurological
Psychiatric
Endocrine
Hematologic and Lymphatic
Date of last transfusion
Allergic and Immunologic
Musculoskeletal
How long does morning stiffness last in minutes and hours?
List the joints affected by swelling in the last 6 months
For women only
Age when period began
Period regular?
How many days apart?
Date of last period
Date of last pap
Bleeding after menopause?
Number of pregnancies
Number of miscarriages
Lifestyle, Sleep, and Exercise
Caffeinated beverages per day
Cups or glasses
Smoking status
If you smoked in the past, how long ago did you quit?
Do you drink alcohol?
Alcoholic drinks per week
Have you ever been told to cut down on your drinking?
Do you use nonmedical drugs?
If yes, list nonmedical drugs
Do you exercise regularly?
Type of exercise
Exercise amount per week
Minutes or hours
Hours of sleep per night
Do you get enough sleep?
Do you wake feeling rested?
Medical, Treatment, and Family History
Heading
Past Medical History. Do you now or have you ever had:
Other Significant Illnesses
Natural or Alternative Therapies
(chiropractic, magnets, massage, over-the-counter preparations, etc.)
Previous Surgeries (up to 7)
Have you had any fractures?
Have you had any other serious injuries?
Fracture or injury details
Family history
Is your father still living
Is your mother still living
Father's age
Mother's age
Father's health
Mother's health
Father's age at death
Mother's age at death
Father's cause of death
Mother's cause of death
Number of Siblings
Siblings Living
Siblings Deceased
Number of Children
Children Living
Children Deceased
Children’s ages and health

Do you know any blood relative who has had:

Rows	Yes	Relationship
Cancer
Leukemia
Stroke
Colitis
Heart disease
High blood pressure
Bleeding tendency
Alcoholism
Rheumatic fever
Epilepsy
Asthma
Psoriasis
Tuberculosis
Diabetes
Goiter

Medications
Drug allergies?
Please list drug allergies and type of reaction
Present medications. (List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium and other supplements, etc.)
Past medications
NSAIDS (non-steroidal anti-inflammatory drugs)
Please check any you have taken in the past

Pain relievers

Rows	Length of time	Helped a lot	Helped some	Helped not at all	Reactions
Acetaminophen
Codeine
Propoxyphene

Other pain relievers
List other pain relievers you have taken, if they have helped and any reactions

Disease Modifying Antirheumatic Drugs (DMArDS)

Rows	Length of time	Helped a lot	Helped some	Helped not at all	Reactions
Certolizumab
Golimumab
Hydroxychioroquine
Penicillamine
Methotrexate
Azathioprine
Sulfasalazine
Quinacrine
Cyclophosphamide
Cyclosporine A
Etanercept
Infliximab
Tocilizumab

Other DMArDS
List other DMArDS you have taken, if they have helped and any reactions

Osteoporosis Medications

Rows	Length of time	Helped a lot	Helped some	Helped not at all	Reactions
Estrogen
Alendronate
Etidronate
Raloxifene
Fluoride
Calcitonin injection or nasal
Risedronate

Other Osteoporosis medications
List other Osteoporosis medications you have taken, if they have helped and any reactions

Gout Medications

Rows	Length of time	Helped a lot	Helped some	Helped not at all	Reactions
Probenecid
Colchicine
Alloprinol

Other gout medications
List other gout medications you have taken, if they have helped and any reactions

Other medications

Rows	Length of time	Helped a lot	Helped some	Helped not at all	Reactions
Tamoxifen
Tiludronate
Cortisone/Prednisone
Hyaluronan
Herbal or Nutritional Supplements

List any supplements you are taking
Have you participated in clinical trials for new medications?
Please list the clinical trials
Are there stairs to climb at home?
Number of stairs to climb at home
Number of people in your household
Your relationship to and the age of those in your household
Who does most of the housework?
Who does most of the shopping?
Who does most of the yard work?
On the scale below, choose a number which best describes your situation. Most of the time, I function:

1

2

3

4

5

1 is Very poorly, 5 is Very well
What is the hardest thing for you to do?
Are you receiving disability benefits?
Are you applying for disability benefits?
Do you have a medically related lawsuit pending?
Which activities of daily living are difficult for you?

Other

Because of health problems, do you have difficulty:

Rows	Usually	Sometimes	No
Using your hands to grasp small objects? (buttons, toothbrush, pencil, etc)
Walking?
Climbing stairs?
Descending stairs?
Sitting down?
Getting up from chair?
Touching your feet while seated?
Reaching behind your back?
Dressing yourself?
Going to sleep?
Staying asleep due to pain?
Obtaining restful sleep?
Bathing?
Eating?
Working?
Getting along with family members?
ln your sexual relationship?
Engaging in leisure time activities?
With morning stiffness
Do you use a cane, crutches, walker or wheelchair?

Which mobility aid do you use?
Should be Empty:

Rheumatology Intake Form

Appointment and Patient Information

Symptoms and Rheumatologic History

Screening and Systems Review

For women only

Lifestyle, Sleep, and Exercise

Medical, Treatment, and Family History

Heading

Family history

Medications

Past medications