"Patient Medical History Form - the Seattle Arthritis Clinic"

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Jeff R. Peterson, MD
Julie L. Carkin, MD
Richard A.H. Jimenez, MD
Philip E. Moberg, MD
Steven S. Overman, MD, MPH
Seattl
Andrew K. Solomon, MD
10330 Meridian Ave N., Suite 250  Seattle, WA 98133
Heather Kramm, MD
Ph: (206) 368-6123 Fax: (206) 368-6178
Myla Morales-Tomas, ARNP
PATIENT HISTORY FORM
Date of first appointment:
/
/
Time of appointment:________________ Birthplace: ________________
MONTH DAY YEAR
Name________________________________________________________________________ Birthdate
/
/
MONTH DAY YEAR
LAST
FIRST
MIDDLE INITIAL
MAIDEN
Address:____________________________________________________________________ Age:________ Sex:  F  M
STREET
APT#
___________________________________________________________________________ Telephone: Home (
)
CITY
STATE
ZIP
Work (
)
MARITAL STATUS:
 Never Married
 Married
 Divorced
 Separated
 Widowed
 Partnered
Spouse/Significant Other:  Alive/Age_____
 Deceased/Age _____
 Major Illness_____________________________________
EDUCATION (Circle highest level attended)
Grade School 7 8 9 10 11 12
College 1 2 3 4
Graduate School _________________________________
Occupation _________________________________________ Number of Hours worked/average per week_______________
Referred here by: (Check one)
 Self
 Family
 Friend
 Doctor
 Other Health Professional
Name of person making referral: ___________________________________________________________________________________
The name of the physician providing your primary medical care: _________________________________________________________
Do you have an orthopedic surgeon?  Yes
 No if yes, Name: ______________________________________________________
Describe your present symptoms: _______________________
___________________________________________________
___________________________________________________
___________________________________________________
Date symptoms began (approximate):____________________
Diagnosis: __________________________________________
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
problem: _____________________________________________
_____________________________________________________
RHEUMATOLOGIC (ARTHRITIS) HISTORY
At any time have you or a blood relative had any of the following? (Check if “yes”)
Relative
Relative
Yourself
Yourself
Name/Relationship
Name/Relationship
Arthritis (unknown type)
Lupus or “SLE”
Osteoarthritis
Rheumatoid Arthritis
Gout
Ankylosing Spondylitis
Childhood arthritis
Osteoporosis
Other arthritis conditions:
Patient’s Name _____________________________________________ Date ___________________ Physician Initials __________
A-1520 (4/13)
Jeff R. Peterson, MD
Julie L. Carkin, MD
Richard A.H. Jimenez, MD
Philip E. Moberg, MD
Steven S. Overman, MD, MPH
Seattl
Andrew K. Solomon, MD
10330 Meridian Ave N., Suite 250  Seattle, WA 98133
Heather Kramm, MD
Ph: (206) 368-6123 Fax: (206) 368-6178
Myla Morales-Tomas, ARNP
PATIENT HISTORY FORM
Date of first appointment:
/
/
Time of appointment:________________ Birthplace: ________________
MONTH DAY YEAR
Name________________________________________________________________________ Birthdate
/
/
MONTH DAY YEAR
LAST
FIRST
MIDDLE INITIAL
MAIDEN
Address:____________________________________________________________________ Age:________ Sex:  F  M
STREET
APT#
___________________________________________________________________________ Telephone: Home (
)
CITY
STATE
ZIP
Work (
)
MARITAL STATUS:
 Never Married
 Married
 Divorced
 Separated
 Widowed
 Partnered
Spouse/Significant Other:  Alive/Age_____
 Deceased/Age _____
 Major Illness_____________________________________
EDUCATION (Circle highest level attended)
Grade School 7 8 9 10 11 12
College 1 2 3 4
Graduate School _________________________________
Occupation _________________________________________ Number of Hours worked/average per week_______________
Referred here by: (Check one)
 Self
 Family
 Friend
 Doctor
 Other Health Professional
Name of person making referral: ___________________________________________________________________________________
The name of the physician providing your primary medical care: _________________________________________________________
Do you have an orthopedic surgeon?  Yes
 No if yes, Name: ______________________________________________________
Describe your present symptoms: _______________________
___________________________________________________
___________________________________________________
___________________________________________________
Date symptoms began (approximate):____________________
Diagnosis: __________________________________________
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
problem: _____________________________________________
_____________________________________________________
RHEUMATOLOGIC (ARTHRITIS) HISTORY
At any time have you or a blood relative had any of the following? (Check if “yes”)
Relative
Relative
Yourself
Yourself
Name/Relationship
Name/Relationship
Arthritis (unknown type)
Lupus or “SLE”
Osteoarthritis
Rheumatoid Arthritis
Gout
Ankylosing Spondylitis
Childhood arthritis
Osteoporosis
Other arthritis conditions:
Patient’s Name _____________________________________________ Date ___________________ Physician Initials __________
A-1520 (4/13)
SYSTEMS REVIEW
As you review the following list, please check any of those problems, which have significantly affected you.
/
/
/
/
/
/
Date of last mammogram __________________ Date of last eye exam ________________ Date last chest x-ray ________________
/
/
/
/
Date of last Tuberculosis Test _________________ Date of last bone densitometry________________
Constitutional
Gastrointestinal
Integumentary (skin and/or breast)
 Recent weight gain
 Nausea
 Easy Bruising
amount________________
 Vomiting of blood or coffee ground material
 Redness
 Recent weight loss
 Stomach pain relieved by food or milk
 Rash
amount________________
 Jaundice
 Hives
 Fatigue
 Increasing constipation
 Sun sensitive (sun allergy)
 Weakness
 Persistent diarrhea
 Tightness
 Fever
 Blood in stools
 Nodules/bumps
Eyes
 Black stools
 Hair loss
 Pain
 Heartburn
 Color changes
of hands or feet in the cold
 Redness
Genitourinary
Neurological System
 Loss of vision
 Difficult urination
 Headaches
 Double or blurred vision
 Pain or burning on urination
 Dizziness
 Dryness
 Blood in urine
 Fainting
 Feels like something in eye
 Cloudy, “smoky” urine
 Muscle spasm
 Itching eyes
 Pus in urine
 Loss of consciousness
Ears-Nose-Mouth-Throat
 Discharge from penis/vagina
 Sensitivity
or pain of hands or feet
 Ringing in ears
 Getting up at night to pass urine
 Memory loss
 Loss of hearing
 Vaginal dryness
 Night sweats
 Nosebleeds
 Rash/ulcers
Psychiatric
 Loss of smell
 Sexual difficulties
 Excessive worries
 Dryness in nose
 Prostate trouble
 Anxiety
For Women only:
 Runny nose
 Easily losing temper
 Sore tongue
Age when periods began:_______________
 Depression
 Bleeding gums
Periods regular?  Yes  No
 Agitation
 Sores in mouth
How many days apart? ________________
 Difficulty falling asleep
 Loss of taste
Date of last period? _______________
 Difficulty staying asleep
/
/
 Dryness in mouth
Date of last pap? ________________
Endocrine
/
/
 Frequent sore throats
Bleeding after menopause?  Yes  No
 Excessive thirst
 Hoarseness
Number of pregnancies? _______________
Hematologic/Lymphatic
 Difficulty in swallowing
Number of miscarriages? _______________
 Swollen glands
Cardiovascular
Musculoskeletal
 Tender glands
 Pain in chest
 Morning stiffness
 Anemia
 Irregular heart beat
Lasting how long? ____________
 Bleeding tendency
 Sudden changes in heart beat
_______ Minutes ________ Hours
 Transfusion/when _________________
 High blood pressure
 Joint Pain
Allergic/Immunologic
 Heart murmurs
 Muscle Weakness
 Frequent sneezing
Respiratory
 Muscle tenderness
 Increased susceptibility to infection
 Shortness of breath
 Joint swelling
 Difficulty in breathing at night
List joints affected in the last 6 months
 Swollen legs or feet
_____________________________________
 Cough
_____________________________________
 Coughing of blood
_____________________________________
 Wheezing (asthma)
_____________________________________
_____________________________________
Patient’s Name _____________________________________________ Date ___________________ Physician Initials __________
A-1520 (4/13)
SOCIAL HISTORY
PAST MEDICAL HISTORY
PAST MEDICAL HISTORY
Do you drink caffeinated beverages?
Do you now or have you ever had: (check if “yes”)
Do you now or have you ever had: (check if “yes”)
 Cancer
 Cancer
 Heart problems
 Heart problems
 Asthma
 Asthma
Cup/glasses per day? _____________________________
 Goiter
 Goiter
 Leukemia
 Leukemia
 Stroke
 Stroke
Do you smoke?  Yes  No  Past- How long ago? _________
 Cataracts
 Cataracts
 Diabetes
 Diabetes
 Epilepsy
 Epilepsy
Do you drink alcohol?  Yes  No Number per week ______
 Nervous breakdown
 Nervous breakdown
 Stomach ulcers
 Stomach ulcers
 Rheumatic
 Rheumatic
Fever
Fever
Has anyone ever told you to cut down on your drinking?
 Bad headaches
 Bad headaches
 Jaundice
 Jaundice
 Colitis
 Colitis
 Yes  No
 Kidney disease
 Kidney disease
 Pneumonia
 Pneumonia
 Psoriasis
 Psoriasis
Do you use drugs for reasons that are not medical?  Yes  No
 Anemia
 Anemia
 HIV/AIDS
 HIV/AIDS
 High
 High
Blood Pressure
Blood Pressure
If yes, please list: _____________________________________
 Emphysema
 Emphysema
 Glaucoma
 Glaucoma
 Tuberculosis
 Tuberculosis
____________________________________________________
Other significant illness (please list) _____________________
Other significant illness (please list) _____________________
Do you exercise regularly?  Yes  No
__________________________________________________
__________________________________________________
Type _______________________________________________
Natural or Alternative Therapies (chiropractic, magnets,
Natural or Alternative Therapies (chiropractic, magnets,
massage over-the-counter preparations, etc.)
massage over-the-counter preparations, etc.)
Amount per week _____________________________________
__________________________________________________
__________________________________________________
How many hours of sleep do you get at night? ______________
__________________________________________________
__________________________________________________
Do you get enough sleep at night?
 Yes  No
__________________________________________________
__________________________________________________
Do you wake up feeling rested?
 Yes  No
Previous Operations
Type
Year
Reason
1.
2.
3.
4.
5.
6.
7.
Any previous fractures?  Yes  No Describe:_________________________________________________________________________
Any other serious injuries?  Yes  No Describe:_______________________________________________________________________
FAMILY HISTORY:
IF LIVING
IF DECEASED
Age
Health
Age at Death
Cause
Father
Mother
Number of siblings _________ Number living __________ Number deceased ___________
Number of children ________ Number living __________ Number deceased ___________ List ages of each ________________
Health of Children: ________________________________________________________________________________________
________________________________________________________________________________________________________
Do you know of any blood relative who has or had: (check and give relationship)
 Cancer__________________
 Heart disease _______________
 Rheumatic
 Tuberculosis_____________
Fever _________
 Leukemia _______________
 High
 Epilepsy ______________
 Diabetes _______________
Blood Pressure ____________
 Stroke __________________
 Bleeding tendency ___________
 Asthma ______________
 Goiter _________________
 Colitis __________________
 Alcoholism _________________
 Psoriasis _____________
Patient’s Name _____________________________________________ Date ___________________ Physician Initials __________
A-1520 (4/13)
MEDICATIONS
Drug allergies?  No  Yes To what?__________________________________________________________________________
____________________________________________________________________________________________________________
Type of reaction ______________________________________________________________________________________________
PRESENT MEDICATIONS
(list any medications you are taking, include such items as aspirin, vitamins, laxatives, calcium, and other supplements, etc.)
Dose (include
How long have
Please check: Helped?
Name of Drug
strength & number
you taken this
A Lot
Some
Not AT All
of pills per day)
medication
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
FN 0-10
Please check () the ONE best answer for your abilities at this time:
Without
With
With
UNABLE
At this Moment, are you able to:
Any
SOME
MUCH
To Do
1=0.3 16=5.3
Difficulty
Difficulty
Difficulty
2=0.7 17=5.7
a. Dress yourself, including tying shoelaces and doing buttons?
_____0
_____1
_____2
_____3
3=1.0 18=6.0
b. Get in and out of bed?
_____0
_____1
_____2
_____3
4=1.3 19=6.3
5=1.7 20=6.7
c. Lift a full cup or glass to your mouth?
_____0
_____1
_____2
_____3
6=2.0 21=7.0
d. Walk outdoors on flat ground?
_____0
_____1
_____2
_____3
7=2.3 22=7.3
8=2.7 23=7.7
e. Wash and dry your entire body?
_____0
_____1
_____2
_____3
9=3.0 24=8.0
f. Bend down to pick up clothing from the floor?
_____0
_____1
_____2
_____3
10=3.3 25=8.3
g. Turn regular faucets on and off?
_____0
_____1
_____2
_____3
11=3.7 26=8.7
12=4.0 27=9.0
h. Get in and out of the car, bus, train or airplane?
_____0
_____1
_____2
_____3
13=4.3 28=9.3
i. Walk two miles?
_____0
_____1
_____2
_____3
14=4.7 29=9.7
j. Participate in sports and games as you would like?
_____0
_____1
_____2
_____3
15=5.0 30=10
k. Get a good night’s sleep?
_____0
___ 1.1
___ 2.2
___ 3.3
PN 0-10
l. Deal with feelings of anxiety or nervousness?
_____0
___ 1.1
___ 2.2
___ 3.3
m. Deal with feelings of depression or “blue”?
_____0
___ 1.1
___ 2.2
___ 3.3
PTGL 0-10
1. How much Pain have you been in because of you condition over the past week?
Please indicate below how severe you pain has been:
NO
                    
PAIN AS BAD
RAPID3 0-30
as it could be
PAIN
0 0.5 1 1.5 2 2.0 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10
2. Considering all the ways in which illness and health conditions may affect you at this time,
Please indicate below how you are doing:
VERY
VERY
                    
POORLY
WELL
0 0.5 1 1.5 2 2.0 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10
Patient’s Name _____________________________________________ Date ___________________ Physician Initials __________
A-1520 (4/13)
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