49.pmd

– PRESENT MEDICATIONS –
Drug Allergies
Drug Sensitivities:
List any medications you are taking at this time. Include such items as aspirin, vitamins, laxatives, calcium supplements, etc.) DOSE (Include Strength and
HOW LONG HAVE YOU
PLEASE CHECK: HELPED?
NAME OF DRUG
number of pills per day
TAKEN THIS MEDICATION? A LOT
SOME NOT AT ALL NOT SURE
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PAST MEDICATIONS
Please review this list of “arthritis” medications, as accurately as possible, try to remember which medications you have taken, how long you were taking the medications, the results of taking the medication and list any reactions you may have had. Record your comments in the spaces provided.
LENGTH OF TIME
BENEFICIARY RESULTS (CHECK)
REACTIONS
DRUG NAMES / DOSAGE
(START DATE — END DATE)
(RASH, HEADACHE, ETC.)
GOOD FAIR
Arizona Arthritis & Rheumatology Associates, P.C.
Patient Name ___________________________________ Date__________________ Birth Date ____________________ PRESENT MEDICAL INFORMATION
PREVIOUS TREATMENT FOR THIS PROBLEM (INCLUDE PHYSICAL THERAPY, SURGERY AND INJECTIONS; MEDICATIONS TO BE LISTED LATER) PLEASE LIST THE NAMES OF OTHER PRACTITIONERS YOU HAVE SEEN FOR THIS OR RELATED PROBLEMS: RHEUMATOLOGIC (ARTHRITIS) HISTORY
At any time have you or a blood relative had any of the following? (check if ”yes”) ______________________________ _________ Psoriasis _______ Arthritis (type unknown) ______________________________ _________ Lupus or “SLE” ______________________________ _________ Ankylosing spondylitis ___________________________ ______________________________ _________ Childhood arthritis ______________________________ _________ Osteoporosis ______________________________ _________ Colitis Other arthritis conditions: __________________________________________________________________________________________________ FAMILY HEALTH HISTORY
If Living
If Deceased
Age at Death
Father
Mother
Number of Brothers ________________________________ Number Living ________________ Number Deceased ________________________
Number of Sisters _________________________________ Number Living ________________ Number Deceased ________________________
Number of Pregnancies _________ Number of Living Children ________ Number of Deceased Children ________ List ages of each ______________________________
Number of Miscarriages __________ Are you trying to get pregnant? ______________________________________________________________
Serious Illnesses of children ________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Do you know of any blood relative who has or had: (check and give relationship)Q Cancer _________________________ Q High Blood Pressure ________________________ Q Asthma _______________________________Q Leukemia _______________________ Q Bleeding Tendency _________________________ Q Tuberculosis __________________________Q Stroke__________________________ Q Alcoholism ________________________________ Q Diabetes ______________________________Q Colitis __________________________ Q Rheumatic Fever ___________________________ Q Goiter/Q Heart Disease ___________________ Q Epilepsy __________________________________ PAST PERSONAL MEDICAL HISTORY
Have you had any of the following? If yes, please check and indicate date of onset: _Q High Cholesterol ______________Q Cancer ______________ Q Heart Problems ___________ Q Asthma _________________ Q Goiter/Thyroid Disease _________Q Leukemia ____________ Q Stroke ___________________ Q Cataracts ________________ Q Diabetes _____________________Q Seizure ______________ Q Depression _______________ Q Stomach Ulcers __________ Q Rheumatic Fever ______________Q Bad Headaches _______ Q Hepatitis _________________ Q Colitis __________________ Q Kidney Disease _______________Q Pneumonia ___________ Q Psoriasis _________________ Q Anemia _________________ Q Hypertension _________________Q Valley Fever __________ Q Mental Disorder ___________ Q Bleeding Disorders ____________ Q Irritable Bowel Syndrome ____________Other Significant illness (please list) ________________________________________________________________________________ PREVIOUS OPERATIONS
1) ____________________________________________ 2) ____________________________________________ 3) ____________________________________________ 4) ____________________________________________ 5) ____________________________________________ 6) ____________________________________________ 7) ____________________________________________ Any previous fractures? Q No Q Yes If yes, describe ____________________________________________________________Any prior transfusion? Q No Q Yes Dates ______________________________________________________________________Any other serious injuries? Q No Q Yes If yes, describe __________________________________________________________Childhood illnesses Q Unremarkable ______________________________________________________________________________ EXERCISE
Do you exercise regularly? Q No Q Yes If yes, list exercise typical in a week Do you adhere to a special diet? Q No Q Yes _______________________ ________________________ _______________________ ________________________ _______________________ ________________________ SOCIAL HISTORY
Do you smoke cigarettes? Q Never Q Yes, # packs/day __________ Q Yes but quit how many years ago __________ Do you drink alcohol? Q No Q Yes ______________ #drinks/week (circle): Beer, Wine or SpiritsMarital status Q Never married Q Married Q Divorced Q Separated Q WidowedSpouse Q Alive/age ____________ Q Deceased/age _______________ Major Illness of spouse ___________________________Where were you born and raised? ________________________________________________ How long in AZ? __________________ HOME CONDITIONS
Check one: Q House Q ApartmentDo you have stairs to climb? Q Yes Q No If yes, how many? __________________________Number of people in household _____________________ Relationship, and age of each? ____________________________________Who does most of the housework? ______________________________ Who does most of the shopping? _______________________ EDUCATION (circle highest level attended)
Junior High School High School 10 11 12 Trade School College 1 2 3 4 Graduate School EMPLOYMENT
Occupation: _____________________________________________ Number of hours worked/average per week ________________Employer: _____________________________________________________________________________________________________Retired? Q No Q Yes Disabled? Q No Q Yes If yes, when, why: ________________________________________________ SYSTEMS REVIEW
As you review the following list, please check any of those problems which apply to you.
GENERAL:
STOMACH AND INTESTINES:
NERVOUS SYSTEM:
HEART AND LUNGS:
KIDNEY/URINE/BLADDER:
M U S C L E S / J O I N T S / B O N E S :
Date of last eye exam _______________________ Date of last chest x-ray ___________________ Date of last Tuberculosis test _______________________Height at greatest ____________________________________ Last Bone Density Exam _____________________________________ MENSTRUAL:
Age when periods began: _______________ Periods regular? Q Yes Q No How many days apart _________________ Date of last period ______________ Date of last Pap smear _________________ Bleeding after menopause ___________________________ PRESENT HEALTH QUESTIONNAIRE
On the scale below, circle a number which best describes your situation. Most of the time, I function.
How many pillows do you use to sleep on each night? _______________Do you get enough sleep at night Q Yes Q No Do you wake up feeling rested? Q Yes Q NoBecause of health problems, do you have difficulty: (Please check the appropriate response for each question) Using your hands to grasp small objects: (buttons, toothbrush, pencil, etc.) .
Getting along with other family members? .
Engaging in leisure time activities? .
Do you use a cane, crutches, a walker or wheelchair? (circle item) . What is the hardest thing for you to do? ________________________________________________________________________________Are you receiving disability? .
Do you have a medically related lawsuit pending? .

Source: http://azarthritis.com/forms/Medical_Information.pdf