RHEUMATOLOGY PATIENT HISTORY FORM
Date: _______/_________/________
NAME: Birthdate: _____/______/_____
Last First M. I.
Age:___________ Sex: F M
Marital status: Never married Married Divorced Separated Widowed Partnered/significant other
Whom do we thank for referring you here?
Name of your primary care physician:
Describe briefly your present symptoms:
When did your symptoms start?
What diagnosis have you been given, if any?
Please list the names of other practitioners you have seen for this problem:
Previous treatment for this problem (include physical therapy, surgery, and injections; medications to be listed
later):
1 Physician initials _______
RHEUMATOLOGIC (ARTHRITIS) HISTORY
At any time have you or a blood relative had any of the following? (check if “yes”)
Yourself Relative Name/relationship
Arthritis (type unknown)
Osteoarthritis
Rheumatoid arthritis
Gout
Lupus or “SLE”
Ankylosing spondylitis
Childhood arthritis
Sjogren’s syndrome
Osteoporosis
Psoriasis/psoriatic arthritis
PAST MEDICAL HISTORY
Do you now or have you ever had: (check if “yes”)
Diabetes Heart murmur Crohn’s disease
High blood pressure Pneumonia Colitis
High cholesterol Pulmonary embolism Anemia
Hypothyroidism Asthma Jaundice
Goiter Emphysema Hepatitis
Cancer (type) _________________ Stroke Stomach or peptic ulcer
Leukemia Epilepsy (seizures) Rheumatic fever
Psoriasis Cataracts Tuberculosis
Angina Kidney disease HIV/AIDS
Heart problems Kidney stones
Other significant illnesses (please list):
Previous Operations
Type Year Reason
1.
2.
3.
4.
5.
6.
7.
Any previous fractures? No Yes Describe
Any other serious injuries? No Yes Describe
Do you smoke? Yes No In the past - How long ago? ________
Do you drink alcohol? No Yes : Usual drink: _________ How much: _____________________
Has anyone ever told you to cut down on your drinking? Yes No
Do you use drugs for reasons that are not medical? No Yes If yes, please list: ________________
Do you get enough sleep at night? Yes No
Do you wake up feeling rested? Yes No
2 Physician initials _______
MEDICATIONS
Drug allergies: No Yes To what?
Please list any medications that you are now taking. Include non-prescription medications, such as aspirin, vitamins,
glucosamine, laxatives, calcium, etc.
Name of drug Dose (include strength and number of pills per day)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
PERSONAL HISTORY
What is your highest educational level? High school Some college courses College graduate
Advanced degree
What is your current or past occupation?
Are you currently working? : Yes No If yes, hours/week ______ If not, are you retired disabled sick leave?
Do you receive disability or SSI? Yes No If yes, for what disability?_____________________________________
What date did this disability begin? ____________
With whom do you currently live?
How much exercise do you get each week? What kind of exercise?
FAMILY HISTORY
IF LIVING IF DECEASED
Age Health Age at death Cause
Father
Mother
Number of siblings: _______ Number living ________
Number of children _______ Number living ________ List ages of each ______________________
Health of children:
3 Physician initials _______
SYSTEMS REVIEW
Date of last eye exam ________ Date of last chest x-ray ________
Date of last bone density test ____________
Result of last TB (PPD) test: Never done Negative Positive Date test performed: ___________
GENERAL THROAT BLOOD
Recent weight gain; how much____ Frequent sore throats Anemia
Recent weight loss: how much____ Hoarseness Bleeding tendency
Fatigue Difficulty in swallowing
Weakness Pain in jaw while chewing SKIN
Fever Easy bruising
Night sweats NECK Redness
Swollen glands Rash
MUSCLE/JOINTS/BONES Tender glands Hives
Morning stiffness Sun sensitive
Lasting how long Minutes HEART AND LUNGS Skin tightness
Hours Pain in chest Nodules/bumps
Joint pain Irregular heart beat Hair loss
Muscle weakness Sudden changes in heart beat Color changes of
Joint swelling Shortness of breath hands or feet in the
List joints affected in the last 6 months Difficulty in breathing at night cold (Raynaud’s)
Swollen legs or feet
Cough NERVOUS SYSTEM
Coughing of blood Headaches
Wheezing Dizziness
Fainting or loss of consciousness
STOMACH AND INTESTINES Numbness or tingling in hands/feet
EARS Nausea Memory loss
Ringing in ears Heartburn Muscle weakness
Loss of hearing Stomach pain relieved by food
Vomiting of blood/”coffee grounds” PSYCHIATRIC
EYES Yellow jaundice Depression
Pain Increasing constipation Excessive worries
Redness Persistent diarrhea Difficulty falling asleep
Loss of vision Blood in stools Difficulty staying asleep
Double or blurred vision Black stools
Dryness
Feels like something in eye KIDNEY/URINE/BLADDER For women only:
Difficult urination Age when periods began: ___________
MOUTH Pain or burning on urination Number of pregnancies: ____________
Sore tongue Blood in urine Number of miscarriages: ____________
Bleeding gums Cloudy, “smoky” urine Have you reached menopause?
Sores in mouth Pus in urine No Yes If yes, at what age: ____
Loss of taste Discharge from penis/vagina Date of last Pap smear: ____________
Dryness Frequent urination Date of last mammogram: ___________
Recent increase in tooth cavities Getting up at night to pass urine
Vaginal dryness If you are still having periods:
NOSE Rash/ulcers Are they regular? Yes No
Nosebleeds Sexual difficulties How many days apart? _________
Loss of smell Prostate trouble
4 Physician initials _______
5 Physician initials _______
