Name:______DOB:______
This questionnaire asks for information that no blood tests, X-rays, or any source other than you can give. Please answer each question even if you feel it is not related to you at this time. There are NO right or wrong answers so please answer exactly as you think or feel.
- Who referred you to this clinic:______
- Please place an X in a “NO “ or “YES” line for each of the following conditions you have EVER had. Whenever you answer “YES”, please fill in the ONE best answer about when it BEGAN.
YES YES YES YES
IN THE LAST2 MONTHS- 1-5 More than 5
NO 2 months 1 year ago years ago ago
High blood pressure (hypertension) ______
Heart attack ______
Angina (chest pain) ______
Other heart disease ______
Congestive heart failure ______
Stroke ______
Mini-stroke (TiA) ______
Skin Cancer (melanoma) ______
Skin Cancer (not melanoma) ______
Lymphoma ______
Lung cancer ______
Breast cancer ______
Other cancer (type)______
Bronchitis or emphysema ______
Anemia (low red blood count) ______
Other blood problem (describe)______
Stomach or duodenal (peptic) ulcer ______
Gastrointestinal bleed GI bleed) ______
Thyroid problem ______
Diabetes ______
Psoriasis ______
Back or spine problems ______
Osteoporosis ______
Broken bones after age 50 ______
Cataracts ______
Depression (feeling blue) ______
Alcoholism ______
Liver disease ______
Fibromyalgia ______
PLEASE TURN PAGE OVER This page reviewed by (provider initials)______
Name:______DOB:______
- Have you had any of the following surgeries? Please mark an X on all lines that apply.
Replacement (arthroplasty) of: Other surgeries?
__left knee __right knee __open heart __Chest (not open heart)
__left hip __right hip __Abdomen __Hysterectomy
__left knuckles __right knuckles __Prostate __Breast
__left shoulder __right shoulder __Angioplasty or stent __other
4.Check here ______if you have not had any of the above surgeries.
5.Have you ever been hospitalized overnight for any of the following? Please mark all that apply.
__Surgery __Heart __Ulcer __Pneumonia __other infection __other reason __no hospitalization
NOTE: If your family history is completely unknown to you, please mark an X here______and go on to #7.
On each row below, please read the disease and then put an X in the boxes under any family member who have had it.
FAMILY HISTORY / Father / Mother / Brother(s) / Sister(s)Heart attack before age 60
Cancer of colon or rectum
Any other cancer
Diabetes Mellitus
Stroke before age 60
Alzheimer’s Disease
Fracture of hip, spine or wrist AFTER age 50
6. On each row below, please read the disease and then put an X in the boxes under any family member who have had it. FAMILY HISTORY
Father / Mother / Brother(s) / Sister(s) / Child / Aunt / UncleRheumatoid arthritis
Osteoarthritis or degenerative arthritis
Lupus (SLE)
Osteoporosis
Psoriatic arthritis
Psoriasis
PLEASE TURN PAGE OVER This page reviewed by (provider initials)______
Name:______DOB:______
- Please mark an X next to any medical condition/symptoms you have had in the past 2 months.
__infection requiring hospitalization __Pregnancy __wheezing
__Pneumonia requiring hospitalization __Shortness of breath __dizziness
__fever __pain in chest __numbness or tingling of arms/legs
__weight gain > 10 lbs __heart pounding __anxiety (feeling nervous)
__weight loss > 10 lbs __swelling of ankles (edema) __problems with thinking /confusion
__head aches __constipation __problems with memory ?forgetfulness
__unusual fatigue __diarrhea __problems with sleeping
__loss of appetite __dark or bloody stools __trouble swallowing
__skin rash or hives __dry eyes __heartburn or stomach gas
__loss of hair __sores in the mouth __stomach pain or cramps
__muscle pain, aches, cramps __dry mouth __nausea
__muscle weakness __cough __vomiting
__Check here if you haven’t had ANY of these medical conditions.
- Please indicate the drug(s) you are currently taking.
-Disease modifying medications (DMARDS)
__I am not taking any of the following arthritis medications. (oral, injectable or infusion)
ORAL medications: __Arava (leflunomide) __Methotrexate (tablets or liquid) __other DMARD(s)__Azulfidine (sulfasalazine) __Minocin (minocycline) __Plaquenil (hydroxychloroquine)
__Imuran ( azathioprine) __Neoral ( cyclosporine)
Injectable medications: __Cimzia (certolizumab) __kineret (anakinra)
__Enbrel ( etanercept) __Methotrexate (injection)
__Humira ( adalimumab) __Simponi (golimumab)
If you use injectable medications:
Have you ever experienced redness or a rash at the site of the injection at least once? __yes __no
Have you ever experienced a painful, stinging or burning sensation at the site of the injection at least once? __yes __no
Infusion medications: __Actemra (tocilzumab)
__Orencia (abatacept) Date of most recent infusion______
__Remicade (inflizimab)
__Rituxin (rituximab)
For patients receiving intravenous infusions: have you EVER experienced any of the symptoms below during or within 24 hours of receiving this infusion? ___yes ___no
(chest tightness, change in blood pressure, rash, palpitations, breathing problems.)
__Aspirin (81 mb [baby] or 325mg) Osteoporosis drugs
NSAIDS (non steroidalantiinflammatories) __I am NOT taking any osteoporosis drugs
__I am NOT taking any NSAIDS __actonel (risedronate) __Miacalcin (calcitonin)
__advil, motrin, or nuprin (ibuprofen) __aredia (pamidronate) __boniva (ibandronate)
__aleve or naprosyn (naproxen) __didronel (etidronate) __reclast (zoledronic acid)
__celebrex ( celecoxib) __estrogen(not a cream)__other osteoporosis drug
__voltaren (diclofenac) __voltaren gel __evista __I’m not sure
__other prescription NSAID(s) [e.g.lodine (etodolac), __forteo __calciium
Relafen (nabumetone), mobic (meloxicam)] __fosamax __vitamin D
PLEASE TURN PAGE OVER This page reviewed by (provider initials)______
.Name:______DOB:______
8.(continued) …Do you take a medication for reflux or toprevent peptic ulcer disease (prescription or over the counter)? __yes __no
Do you take antidepressant medication? __yes __no
Do you take narcotic pain medication (e.g. vicodin, lortab, Percocet)? __yes __no
Over the past 3 months have you taken a medrol dose pack? __yes __no
Are you currently on a medrol dose pack? __yes __no
Over the past 3 months have you taken any prednisone? (if yes, please mark the most recent dose)
__no __yes __1mg __2-2.5mg __3-4mg __5-7mg __7.5-9mg __10mg or more daily
- Which of the following have you taken OVER THE PAST 8 WEEKS?
__other cholesterol lowering drugs (i.e. Niacin, niaspan, zetia __plavix __coumadin
__chondroitin __folic acid __fish oil __evening primrose oil __borage seed oil
__limbrel __flax seed oil __other non prescription remedy or remedies
__put X here if you have not taken ANY of these over the last 8 weeks
- When you get up in the morning, do you feel stiff? __yes __no
- If your answer to question #10 was yes, how long does it take until you are as limber as you will be for the day?
Enter the number of hours and/or minutes:______hours _____minutes
Do you exercise? __not at all __ 1-2 times per week __ 3-4 times per week __5-6 times per week __daily- Have you ever smoked a total of 100 cigarettes or more over your lifetime? __yes __no
If Yes: how old were you when you first started smoking? ______
On average, for all the time you smoked, how many cigarettes did you usually smoke in a day?______
Do you currently smoke cigarettes? __yes __no
If previous smoker: how old were ou when you last smoked cigarettes?______
In total, how long have you smoked in your life? ____years ______months
- In the past year, how often (on average) did you drink any type of alcoholic beverage (includes beer/wine)
In the past year, on days you drank alcoholic beverages, (on average) how many drinks did you have?______
In the past year, how many days did u have 3 drinks or more?____days per day / week / month (circle one)
- Your height _____ft_____in
- Current (primary) work status: __full time __part time __not working outside the home with pay
If currently working, what is your occupation?______
- Number of days you were unable to do your usual work inside or outside your home over the past 3 months because of arthritis.
- Who do you live with? ___spouse/partner ___sibling(s) ___parents ___son/daughter ___alone
- Your insurance type: ___private______medicare __medicaid __no insurance
PLEASE TURN PAGE OVER This page reviewed by (provider initials)______
FOCUS Health Assessment Questionnaire
Name:______DOB:______
Place an X in the box which best describes without any with some with much unable
your usual abilities OVER THE PAST WEEK: difficulty (0) difficulty (1) difficulty (2) to do (3)
dress yourself, shoelaces and buttons □ □ □ □shampoo your hair? □ □ □ □
Get in and out of bed ? □ □ □ □
Stand up from a straight chair? □ □ □ □
Lift a full cup or glass to your mouth? □ □ □ □
Cut your meat? □ □ □ □
Open a new milk carton □ □ □ □
Walk outdoors on flat ground? □ □ □ □
Climb up five steps? □ □ □ □
____(D)
____(A)
____(E)
____(W)
Circle any AIDS or DEVICES that you usually use for any of the above activities:
Cane (W) Crutches(W) Wheelchair (W) Built up or special utensils (W)
Devices for dressing (button hook, zipper pull, long handled shoe horn) (D) Special built up chair(A)
Other (please specify)______(W,E,A,D)
Circle any categories for which you usually need HELP FROM ANOTHER PERSON:
Dressing and grooming (D) Arising(A) Eating (E) Walking (W)
Place an X in the box which best describes without any with some with much unable
your usual abilities OVER THE PAST WEEK: difficulty (0) difficulty (1) difficulty (2) to do (3)
Wash and dry your body ? □ □ □ □Take a tub bath? □ □ □ □
Get on and off the toilet?
Bend down and pick up clothing ? □ □ □ □
Reach a 5 lb bag from over your head? □ □ □ □
Turn faucets on and off? □ □ □ □ open jars previously opened? □ □ □ □
Open car doors?
Get in and out of a car? □ □ □ □
Run errands and shop ? □ □ □ □
Do chores, vacuuming and yard work? □ □ □ □
____(H)
____(R)
____(G)
____(E/C)
Circle any AIDS or DEVICES that you usually use for any of the above activities:
Bathtub bar (H) Raised toilet seat (H) jar opener for previously opened jars (G)
Long handled appliances in bathroom (H) Long handled appliances for reach (R)
Other (please specify)______(H,G,R,E/C)
Circle any categories for which you usually need HELP FROM ANOTHER PERSON:
Hygiene (H) Reach(R) Gripping and opening things(G) Errands and chores (E/C) (please turn page over)
1=0.125, 2=0.25, 3=0.375, 4=0.5, 5=0.625, 6=0.75, 7=0.875, 8=1, 9=1.125, 10=1.25, 11=1.375, 12=1.5, 13=1.625, 14=1.75, 15=1.875, 16=2, 17=2.175, 18=2.25, 19=2.375, 20=2.5, 21=2.625, 22=2.75, 23=2.875
PLEASE TURN PAGE OVER This page reviewed by (provider initials)______
Name:______DOB:______
PAIN: How much pain have you had because of your arthritis in the past week? Put a mark on the scale (like this I ) to
show how severe your pain has been.
NO PAIN .___.___.___.___.___.___.___.___.___.___.___.___.___.___.___.___.___.___.___.___. PAIN AS BAD
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 AS IT COULD BE
DISEASE ACTIVITY: Considering all the ways arthritis affects you, put a mark on the scale (like this I ) to show how well
you are doing.
VERY WELL .___.___.___.___.___.___.___.___.___.___.___.___.___.___.___.___.___.___.___.___. VERY POORLY
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
FATIGUE: How much of a problem has unusual fatigue or tiredness been for you IN THE PAST WEEK? Put a mark (like this I ) on the line below that best describes the severity of our fatigue on a scale of 0 – 100.
Fatigue is no problem .___.___.___.___.___.___.___.___.___.___.___.___.___.___.___.___.___.___.___.___. Fatigue is major problem
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
Please list any DRUG allergies you have:
______
Please list your current medications (not already mentioned) with strength and doseage: (or you can bring a list of your own)
______
______
______
______
Please list your pharmacy name and address:
______
______
Do you use mail order? ___yes ___no
You now have completed the initial paperwork! Thank you for taking the time now, that will make your visit to The Rheumatology and Immunotherapy Center even more efficient.
This page reviewed by (provider initials)______
9/2014