New Patient Inquiry

Dateoffirstappointment: / / Timeofappointment: Birthplace:

MONTHDAYYEAR

Name: Birthdate: / /

LASTFIRSTMIDDLEINITIALMAIDENMONTHDAYYEAR

Address: Age: Sex:‰F ‰M

STREETAPT#

Telephone:Home ( )

CITYSTATEZIPWork ()

MARITALSTATUS: ‰NeverMarried ‰Married ‰Divorced ‰Separated ‰Widowed

Spouse/SignificantOther: ‰Alive/Age ‰Deceased/Age MajorIllnesses

EDUCATION (circlehighestlevelattended):

GradeSchool78910 11 12College1234GraduateSchool Occupation Numberofhoursworked/averageperweek

Referredhereby:(checkone) ‰Self ‰Family ‰Friend ‰Doctor ‰OtherHealthProfessional

MEDICAL HISTORY

As youreviewthe followinglist,pleasecheckanyofthoseproblems,whichhavesignificantlyaffectedyou.

Dateoflastmammogram Dateof lasteyeexam Dateoflastchest x–ray DateoflastTuberculosisTest Dateoflastbonedensitometry

Constitutional

☐Recentweightgain

amount

☐Recentweightloss

amount

☐Fatigue

☐Weakness

☐Fever

Eyes

☐Pain

☐Redness

☐Lossof vision

☐Doubleorblurredvision

☐Dryness

☐Feelslikesomethingineye

☐Itchingeyes

Ears–Nose–Mouth–Throat

☐Ringingin ears

☐Lossof hearing

☐Nosebleeds

☐Lossof smell

☐Drynessin nose

☐Runnynose

☐Soretongue

☐Bleedinggums

☐Soresinmouth

☐Lossof taste

☐Drynessofmouth

☐Frequentsorethroats

☐Hoarseness

☐Difficultyin swallowing

Cardiovascular

☐Paininchest

☐Irregularheartbeat

☐Suddenchangesinheartbeat

☐Highbloodpressure

☐Heartmurmurs

Respiratory

☐Shortnessofbreath

☐Difficultyin breathingat night

☐Swollenlegsorfeet

☐Cough

☐Coughingof blood

☐Wheezing(asthma)

Gastrointestinal

☐Nausea

☐Vomitingofbloodorcoffeegroundmaterial

☐Stomachpainrelievedbyfoodormilk

☐Jaundice

☐Increasingconstipation

☐Persistentdiarrhea

☐Bloodinstools

☐Blackstools

☐Heartburn

Genitourinary

☐Difficulturination

☐Painorburningonurination

☐Bloodinurine

☐Cloudy,“smoky”urine

☐Pusin urine

☐Dischargefrom penis/vagina

☐Gettingupat nightto passurine

☐Vaginaldryness

☐Rash/ulcers

☐Sexualdifficulties

☐Prostatetrouble

ForWomenOnly:

Agewhenperiodsbegan:Periods regular?☐Yes☐No

Howmanydaysapart?

Date oflastperiod? ______

Dateoflastpap? ______

Bleedingaftermenopause?☐Yes☐No Numberofpregnancies?

Numberofmiscarriages?

Musculoskeletal

☐Morningstiffness

Lastinghowlong?

Minutes Hours

☐Jointpain

☐Muscleweakness

☐Muscletenderness

☐Jointswelling

Listjointsaffectedinthelast6mos.

Integumentary(skinand/orbreast)

☐Easybruising

☐Redness

☐Rash

☐Hives

☐Sunsensitive(sunallergy)

☐Tightness

☐Nodules/bumps

☐Hair loss

☐Colorchangesofhandsorfeet in the cold

NeurologicalSystem

☐Headaches

☐Dizziness

☐Fainting

☐Musclespasm

☐Lossof consciousness

☐Sensitivityorpainofhandsand/orfeet

☐Memoryloss

☐Nightsweats

Psychiatric

☐Excessiveworries

☐Anxiety

☐Easilylosingtemper

☐Depression

☐Agitation

☐Difficultyfallingasleep

☐Difficultystayingasleep

Endocrine

☐Excessivethirst

Hematologic/Lymphatic

☐Swollenglands

☐Tenderglands

☐Anemia

☐Bleedingtendency

☐Transfusion/when

Allergic/Immunologic

☐Frequentsneezing

☐Increasedsusceptibilityto infection

SOCIALHISTORY

Do youdrinkcaffeinatedbeverages?

Cups/glassesperday?

Doyousmoke?☐Yes☐No☐Past– Howlongago?

Doyoudrinkalcohol?☐Yes☐NoNumberperweek

Has anyoneevertoldyoutocutdownon yourdrinking?

☐Yes☐No

Do youusedrugsforreasonsthatarenotmedical?☐Yes☐No

Ifyes,pleaselist:

Do youexerciseregularly?☐Yes☐No

Type

Amount perweek

Howmanyhoursofsleepdoyougetatnight?

Do yougetenoughsleepat night? ☐Yes☐No

Do youwakeupfeelingrested? ☐Yes☐No

PASTMEDICALHISTORY

Do younoworhaveyoueverhad: (checkif “yes”)

☐Cancer☐Heartproblems☐Asthma

☐Goiter☐Leukemia☐Stroke

☐Cataracts☐Diabetes☐Epilepsy

☐Nervousbreakdown☐Stomach ulcers☐Rheumaticfever

☐Bad headaches☐Jaundice☐Colitis

☐Kidney disease☐Pneumonia☐Psoriasis

☐Anemia☐HIV/AIDS☐High Blood Pressure

☐Emphysema☐Glaucoma☐Tuberculosis

Othersignificantillness(pleaselist) ______

NaturalorAlternativeTherapies(chiropractic,magnets,massage, over-the-counterpreparations,etc.)

______

Previous Operations

Type / Year / Reason
1.
2.
3.
4.
5.
6.
7.

Anypreviousfractures?☐No☐Yes Describe:Anyotherseriousinjuries?☐No☐Yes Describe:

FAMILYHISTORY:

IFLIVING
AgeHealth / IFDECEASED
Ageat DeathCause
Father
Mother

Numberofsiblings Numberliving Numberdeceased

Numberof children Numberliving Numberdeceased Listagesof each Healthofchildren:

Do youknowof anybloodrelativewhohasorhad:(checkandgiverelationship)

☐Cancer

☐Leukemia

☐Stroke

☐Colitis

☐Heartdisease

☐Highbloodpressure

☐Bleedingtendency

☐Alcoholism

☐Rheumaticfever

☐Epilepsy

☐Asthma

☐Psoriasis

☐Tuberculosis

☐Diabetes

☐Goiter

MEDICATIONS

Drugallergies:☐No☐YesTowhat?

Typeofreaction:

PRESENTMEDICATIONS (List anymedicationsyouaretaking. Includesuchitemsasaspirin,vitamins,laxatives, calciumandothersupplements, etc.)

NameofDrug / Dose(include strengthnumberof pillsperday) / Howlonghave youtakenthis medication / Pleasecheck: Helped?
ALotSomeNotAtAll
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

PASTMEDICATIONSPleasereviewthis listof “arthritis”medications.As accuratelyaspossible,tryto rememberwhichmedicationsyou have taken,howlongyouweretakingthemedication,theresults of takingthemedicationand listanyreactionsyoumayhavehad.Recordyour commentsin thespacesprovided.

Drugnames/Dosage / Lengthof time / Pleasecheck: Helped?
ALotSomeNotAtAll / Reactions
Non-SteroidalAnti-InflammatoryDrugs(NSAIDs)
Checkanyyouhavetakeninthepast
Ansaid(flurbiprofen)
Arthrotec(diclofenac+misoprostil)
Aspirin(includingcoatedaspirin)
Celebrex(celecoxib)
Clinoril(sulindac) Daypro(oxaprozin)
Disalcid(salsalate)
Dolobid(diflunisal)
Feldene(piroxicam)
Indocin(indomethacin)
Lodine(etodolac)
Meclomen(meclofenamate)
Motrin/Rufen(ibuprofen)
Nalfon(fenoprofen)
Naprosyn(naproxen)
Oruvail(ketoprofen)
Tolectin(tolmetin)
Trilisate(cholinemagnesiumtrisalicylate)
Vioxx(rofecoxib)
Voltaren(diclofenac)
PainRelievers
Acetaminophen(Tylenol)
Codeine(Vicodin, Tylenol3)
Propoxyphene(Darvon/Darvocet)
Other:
Other:
DiseaseModifyingAntirheumaticDrugs(DMARDS)
Auranofin, goldpills(Ridaura)
Goldshots(MyochrysineorSolganol)
Hydroxychloroquine(Plaquenil)
Penicillamine (CuprimineorDepen)
Methotrexate(Rheumatrex)
Azathioprine(Imuran)
Sulfasalazine(Azulfidine)
Quinacrine(Atabrine)
Cyclophosphamide(Cytoxan)
CyclosporineA(SandimmuneorNeoral)
Etanercept(Enbrel)
Infliximab(Remicade)
ProsorbaColumn
Other:
Other:
OsteoporosisMedications
Estrogen (Premarin,etc.)
Alendronate(Fosamax)
Etidronate(Didronel)
Raloxifene(Evista)
Fluoride
Calcitonininjectionor nasal(Miacalcin,Calcimar)
Risedronate(Actonel)
Other:
Other:
GoutMedications
Probenecid(Benemid)
Colchicine
Allopurinol(Zyloprim/Lopurin)
Other:
Other:
Others
Tamoxifen(Nolvadex)
Tiludronate(Skelid)
Cortisone/Prednisone
Hyalgan/Synviscinjections
HerbalorNutritionalSupplements
Pleaselist supplements:

Haveyouparticipatedinanyclinicaltrialsfornewmedications?☐Yes☐No

If yes,list:

ACTIVITIESOFDAILYLIVING

Doyouhavestairstoclimb? ☐Yes ☐NoIfyes,howmany?

Howmanypeopleinhousehold? Relationshipandageof each

Whodoesmostof thehousework? Whodoesmostof theshopping? Whodoesmostof theyardwork?

On thescalebelow,checkwhichbest describesyoursituation;Mostofthetime,Ifunction…

VERY / POORLY / OK / WELL / VERY
POORLY / WELL

Becauseof healthproblems,do youhavedifficulty:

(Pleasecheckthe appropriateresponseforeachquestion.)

Usually / Sometimes / No
Usingyourhandsto graspsmallobjects?(buttons,toothbrush,pencil,etc.)
Walking?
Climbingstairs
Descendingstairs
Sittingdown
Gettingupfromchair
Touchingyourfeetwhileseated
Reachingbehindyourback
Reachingbehindyourhead?
Dressingyourself?
Goingtosleep?
Stayingasleepdue to pain?
Obtainingrestfulsleep?
Bathing?
Eating?
Working?
Gettingalong withfamilymembers?
In yoursexualrelationship?
Engagingin leisuretimeactivities?
Withmorningstiffness?
Do youusea☐cane,☐crutches,as☐walkerora ☐wheelchair?

Whatisthe hardestthingforyoutodo?

Areyoureceivingdisability? / Yes☐ No☐
Areyouapplyingfordisability? / Yes☐ No☐
Do youhaveamedicallyrelatedlawsuitpending? / Yes☐ No☐