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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

Microsoft word - patient health history pg1.doc

Patient Name______________________________________Date______________________________ Medical Physician’s Name & Phone___________________________________________________________ Please answer the following health questions as completely as possible (circle YES or NO) 1. Do you consider yourself to be in good health? 2. Are you now or have you been under a physicians care within the

Verbale 8_seduta 8 relazione finale

Procedura di valutazione comparativa per la copertura di n. 1 posto di Ricercatore universitario presso l’Università degli Studi di Genova, Facoltà di Medicina e Chirugia, settore scientifico – disciplinare MED/38 Pediatria Generale e Specialistica.- D.R. n. 324 del 14 Maggio 2008, pubblicato nella Gazzetta Ufficiale n.43, IV Serie Speciale del 3/06/2008 RELAZIONE La Commissione,

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