Office Use nly Dctr: LRDC Chart #: Appintment Date: Little Rck Diagnstic Clinic Rheumatlgy - Patient Questinnaire This infrmatin will becme part f the medical recrd and is subject t federal privacy laws. Full Name: Date f Birth: E-mail address: Cell Phne: Circle all that apply: tbacc use high bld pressure diabetes heart disease Describe the medical prblem r reasn that yu are here fr evaluatin tday. When did it start? Hw lng des it last? Where is it lcated? Hw severe is it? Hw ften des it ccur? Aggravated by? Relieved by? Vitals This bx will be cmpleted by the nursing staff at the Prvider s ffice Please DO NOT write. Ht WT Temp BP Pulse Resp Pulse x
Please list the medicatins yu are currently taking. Please include all ver-the-cunter and herbal medicatins (use back f page if needed): Medicatin Name Dsage Hw ften Started Prblem medicatin fr Dctr wh wrte Pharmacy Name and Address D yu get yur medicatins fr 30 days r 90 days at a time? (circle ne) 30 days 90 days Please list any drug allergies r side effects (use back page if needed) When Drug Describe Reactin Immunizatins (list date f last) Tetanus Pneumnia Shingles Flu List all the physicians that yu are currently seeing: Physician Name Specialty Cnditin being treated Next Office Visit Wuld yu like a cpy f yur visit sent t this dctr? 2 P a g e
Review f Systems- MEN ONLY Please check a bx belw fr every questin that applies t yur current health General N Yes Urinary N Yes Skin N Yes Chills Dribbling Brittle hair Fatigue Painful urinatin Brittle nails Fever Bld in urine Hair lss Night sweats Excessive urinatin Excessive hair grwth Tired Slw stream Hives Weight gain Increased frequency Itching Weight lss Unable t hld urine Mle changes Truble emptying bladder Rash Skin lesin Head/Neck N Yes Reprductive N Yes Ear drainage Erectin prblems Ear pain Discharge frm penis Musculskeletal N Yes Eye discharge Decreased libid Back pain Eye pain Jint pain Hearing lss Jint swelling Nasal drainage Metablic N Yes Muscle weakness Sinus pressure Cld intlerance Neck pain Sre thrat Heat intlerance Visual changes Always thirsty Always hungry Bld/lymph N Yes Easy bleeding Respiratry N Yes Easy bruising Chrnic cugh Neurlgical N Yes Enlarged lymph ndes Recent cugh Dizziness Knwn TB expsure Numbness in arms/legs Shrtness f breath Weakness in arms/legs Immunity N Yes Wheezing Truble walking Cntact allergy Headache Envirnmental allergy Memry lss Fd allergy Heart N Yes Seizures Seasnal allergy Chest pains Tremrs Leg pain with walking Swelling in legs Heart racing Psychiatric N Yes Anxiety Depressin Gastrintestinal N Yes Truble sleeping Abdminal pain Bld in stls Change in stls Cnstipatin Diarrhea Heartburn Lss f appetite Nausea Vmiting 3 P a g e
Review f Systems- WOMEN ONLY Please check a bx belw fr every questin that applies t yur current health General N Yes Urinary N Yes Psychiatric N Yes Chills Painful urinatin Anxiety Fatigue Bld in urine Depressin Fever Excessive urinatin Truble sleeping Night sweats Increased frequency Tired Unable t hld urine Weight gain Truble emptying bladder Metablic N Yes Weight lss Cld intlerance Heat intlerance Always thirsty Head/Neck N Yes Reprductive N Yes Always hungry Ear drainage Abnrmal pap smear Ear pain Painful perids Eye discharge Painful intercurse Musculskeletal N Yes Eye pain Ht flashes Back pain Hearing lss Irregular perids Jint pain Nasal drainage Vaginal discharge Jint swelling Sinus pressure Muscle weakness Sre thrat Neck pain Visual changes Skin N Yes Brittle hair Brittle nails Bld/lymph N Yes Respiratry N Yes Hair lss Easy bleeding Chrnic cugh Excessive hair grwth Easy bruising Recent cugh Hives Enlarged lymph ndes Knwn TB expsure Itching Shrtness f breath Mle changes Wheezing Rash Immunity N Yes Skin lesin Cntact allergy Envirnmental allergy Heart N Yes Fd allergy Chest pains Neurlgical N Yes Seasnal allergy Leg pain with walking Dizziness Swelling in legs Heart racing Numbness in arms/legs Weakness in arms/legs Truble walking Headache Gastrintestinal N Yes Memry lss Abdminal pain Bld in stls Change in stls Cnstipatin Diarrhea Heartburn Lss f appetite Nausea Vmiting Seizures Tremrs 4 P a g e
Past Medical Histry Place check all that apply t yu Allergies Bld clts Gallbladder disease Kidney disease Anemia Cancer (type) Heartburn/ reflux Seizures Chest pains COPD Hepatitis C Thyrid disease Anxiety Heart Disease High bld pressure Arthritis Depressin Irritable bwel disease Asthma Diabetes Mycardial infarctin Atrial fibrillatin Elevated lipids Osteprsis Past Surgical Histry Place the Year (if knwn) t all that apply t yu Year Year Men Only Year Wmen Only Year Heart Balln Gastric Bypass Prstate Bipsy Breast Implants Appendix Remval Hernia Repair Prstate Surgery Tubal Knee Scpe Hip Replacement Vasectmy Breast Bipsy Back Surgery Knee Replaced C-sectin Bld transfusin LASIK Eye D&C Heart Bypass ORIF Hysterectmy Cardiac Pacemaker Thyrid Remval Mastectmy Carpal Tunnel Tnsil Remval Fibrid Remval Cataract Remval Breast Reductin Intestine Remval Hyst and Ovaries Clstmy Bag Vaginal Hyst 5 P a g e
Family Histry Adpted/unknwn Alive (age) Deceased (at what age) Attentin Deficit Disrder Alchlism Allergies Alzheimer's disease Arthritis Asthma Bld disrder Cancer Type f cancer Heart disease after 50 Heart disease befre 50 Depressin Develpmental Prblems Diabetes Skin prblems Elevated lipids Genetic disease Hearing prblems High bld pressure Irritable bwel disease Learning prblems Mental illness Migraines Obesity Osteprsis Pr circulatin Kidney disease Seizures Strke Lupus Thyrid disrder Place a check mark in the bx t all that apply Mther Father Sister Brther Other Other relevant family histry: 6 P a g e
Scial Histry Tbacc Histry: Smking Tbacc Use Tbacc Use Usage Type: daily per day Years used Age started Age stpped Nn-Smking Tbacc Use Tbacc Use Usage per Type: Daily day Years used Age started Age stpped Cigarette #packs/cig Chewing units Cigarill cigarills Smkeless units Cigar cigars Snuff units Pipe pipes Have yu ever tried t quit smking? N / Yes Year quit? Cessatin methd? Lngest perid tbacc free? Relapsed? Yes / N If s, why? Alchl Histry: N Yes Frmerly (list year quit) Type f alchl Hw frequently Hw much a day? When was yur last drink? Caffeine Histry: Yes N if Yes Type? Servings Per Day Demgraphics: The Federal Gvernment requires us t cllect the fllwing infrmatin. This infrmatin is part f the medical recrd and is subject t privacy laws. Race (must chse ne): American Indian r Alaskan Native Asian Black r African American Native Hawaiian r Other Pacific Islander White Ethnicity (check ne) Hispanic Nn-Hispanic Primary Language Spken: Cuntry f Birth (if nt US): Hand Dminance: Right Left Ambidextrus Educatin: Highest level f Educatin: Any Degree btained: Emplyment: Emplyer: Occupatin: Emplyment Status: If Retired, Date: 7 P a g e
Military Experience: N Yes Branch: Years served: Dmestic: Current Marital Status (circle ne): Single Married Widwed Divrced Previusly widwed? N Yes Previusly divrced? N Yes Children? N Yes # Sns # Daughters Wh lives with yu? Sleep Patterns: Changes in sleep patterns: N Yes Average number f hurs f sleep per night: Truble falling asleep: N Yes Difficulty staying asleep: N Yes Frequent waking episdes at night: N Yes Disrupted breathing, gasping, gagging r N Yes chking fr air during sleep: Lifestyle: Activity level: Mderate Sedentary Vigrus Health club member: Nw Previusly Never Type f exercise: Exercise frequency: Hurs/week: Hbbies/Activities: Current Diet : Animals in the hme: N Yes Type Religius/Spiritual: D yu have a religius affiliatin? N Yes Religin name: Hme Envirnment/Safety: Smke detectrs in hme? N Yes Carbn mnxide detectrs in hme? N Yes Falls in the last year? N Yes Number f falls: Pl/spa at hme: N Yes Seat belt use? N Yes Recent Travel Out f state? Out f cuntry? Knwn expsure t disease? 8 P a g e