Rheumatology np questionnaire revised 11-2004.pdf

THE CONSULTANT GROUP, P.C.
RHEUMATOLOGY NEW PATIENT QUESTIONNAIRE
NAME:____________________________________________________ BIRTHDATE: ___ RACE: __ ____SEX:M F___ RIGHT HANDED( )LEFT HANDED( ) NAME OF PHYSICIAN WHO REFERRED YOU:_______________________________________ ADDRESS:__________________________________________________________________ __________________________________________________________________________ PHONE: (___)_________________ NAME OF YOUR FAMILY PHYSICIAN:____________________________________________ ADDRESS:__________________________________________________________________ __________________________________________________________________________ PHONE: (___)_________________ THE MAIN PROBLEM YOU ARE HAVING:__________________________________________ HOW LONG HAVE YOU BEEN HAVING THIS PROBLEM:_______________________________ HAVE YOU PREVIOUSLY SEEN A RHEUMATOLOGIST? ( ) NO ( ) YES IF SO, WHO, WHEN, WHERE:________________________________________________ PLEASE CHECK (v) IF YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING PROBLEMS: ( ) BLOODY STOOLS
( ) ULCERS
( ) IRRITATED COLON

PAST MEDICAL HISTORY:
PLEASE CHECK IF YOU HAVE HAD ANY OF THE FOLLOWING PROBLEMS:
( ) HEART DISEASE/HEART MURMURS ( ) JAUNDICE/HEPATITIS ( ) STROKE ( ) HIGH BLOOD PRESSURE ( ) KIDNEY DISEASE/KIDNEY STONES ( ) DIABETES ( ) SYSTEMIC LUPUS ERYTHEMATOSUS ( ) OSTEOARTHRITIS ( ) OTHER ______________________________________________________________ HAVE YOU EVER HAD A BLOOD TRANSFUSION? ( ) NO ( ) YES IF SO, WHAT YEAR(S): _____________________________________________ IF SO, DESCRIBE:__________________________________________________ IF SO, DESCRIBE:__________________________________________________ # PREGNANCIES: # LIVE BIRTHS: # MISCARRIAGES:_________ OVER
MEDICATIONS:
LIST ALL MEDICINES YOU ARE ALLERGIC TO:
_______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ LIST ALL MEDICINES YOU ARE CURRENTLY TAKING (con ________________________________ _______ ____________________ ________________________________ _______ ____________________ ________________________________ _______ ____________________ ________________________________ _______ ____________________ ________________________________ _______ ____________________ ________________________________ _______ ____________________ ________________________________ _______ ____________________ PAIN MEDS/NARCOTICS PRESCRIPTIONS WILL NOT BE REFILLED AFTER BUSINESS HOURS PLEASE CIRCLE WHETHER OR NOT YOU HAVE EVER TAKEN THE FOLLOWING MEDICINES: (Y) (N) CORTISONE/PREDNISONE (Y) (N) TOLECTIN (Y) (N) ANY MEDICINE W/ASPIRIN (Y) (N) CELEBREX
SOCIAL HISTORY:
HAVE YOU EVER SMOKED? HOW MUCH? _______________________
FOR HOW MANY YEARS: IF YOU QUIT, HOW LONG AGO? ________________ HAVE YOU EVER TAKEN IV DRUGS/ILLICIT DRUGS? ( ) NO ( ) YES DO YOU DRINK ALCOHOL? HOW MUCH? _________________________________ FOR HOW MANY YEARS: IF YOU QUIT, HOW LONG AGO? ________________ DO YOU DRINK COFFEE? ( ) NO ( ) YES IF SO, HOW MUCH? ARE YOU EMPLOYED OUTSIDE THE HOME? ( ) NO ( ) IF SO, WHAT DO YOU DO? __________________________________________________ HOW MANY HOURS A WEEK? _____________________ ARE YOU ON DISABILITY? ( ) NO ( ) YES WERE YOU ADOPTED? ( ) NO ( ) YES IF YOU HAVE ANY HOBBIES, WHAT ARE THEY? _________________________________ _________________________________________________________________________ EDUCATION:GRADE SCHOOL____, HIGH SCHOOL____, COLLEGE____, POST GRADUATE____ FAMILY HISTORY:
Mother: _____ Y N ______ __________________________ _______________ Father: _____ Y N ______ __________________________ _______________ Sister: _____ Y N ______ __________________________ _______________ Sister: _____ Y N ______ __________________________ _______________ Brother: _____ Y N ______ __________________________ _______________ Brother: _____ Y N ______ __________________________ _______________ HAS ANYONE IN YOUR FAMILY EVER HAD THE FOLLOWING PROBLEMS:
( ) NO ( ) YES ARTHRITIS
( ) NO ( ) YES ANKYLOSING SPONDYLITIS ( ) NO ( ) YES CANCER/LEUKEMIA ( ) NO ( ) YES OSTEOPOROSIS g:shared/medical records/forms/rheum np ?naire Revised 11/2004

Source: http://heneinarthritis.com/Rheumatology_quest.pdf