History Form

About you:

Today’s Date
First Name		Last Name
Birthplace		Date of Birth (MM/DD/YYYY)

Allergies

Are you allergic to any medication?		Yes		No
If yes, to what?		What happened?
	Penicillin
	Sulfa
	Aspirin
	Others
Food allergies (i.e. peanut, egg, shellfish, etc.)		Yes		No
If yes, to what?

Present Symptoms:

Please describe your present symptoms (what brings you in today?)
Were you referred for an abnormal blood test result?	Yes No
If so, what was the concern (check all that apply):
Positive ANA Elevated rheumatoid Factor ESR CRP
Do you have early morning joint stiffness?	Yes No
Do you have pain?	Yes No
Have you ever been seen by a rheumatologist?	Yes No
If so, what was the diagnosis and treatment?

About Your Symptoms

Do your symptoms:

come and go

steady all the time

When do you have your symptoms?
	Morning	Afternoon	Evening	Night
Most
Least

List your symptoms and dates when they began:
	Date		Date
Multiple miscarriages		Hearing loss
Sinusitis		Asthma
Hair loss (balding)		Rash/psoriasis
Fetal death

Symptoms started:

All of a sudden

Gradually

Did you have any of the following prior to the onset of your symptoms?
	Viral syndrome		Stomach virus		Stressful situation		CRP
	Car accident		Other injury		Others:
Previous treatments for this problem:
	Physical Therapy		Surgery		Medication		Injection

Did you ever take corticosteroids?		Yes		No
Did you ever break a bone?		Yes		No

Pain

Please indicate the type of pain and location:

	Side		Aching	Burning	Stabbing	Crampy	Electric shock	Pins and needles	Pulling
	R	L
Fingers
Wrist
Elbow
Shoulder
Hip
Knee
Ankle
Toes
Neck
Mid Back
Low Back
Arm
Muscles
Leg Muscles

What affects your pain?

	Rest	Activity	Medication	Exercises	Ice	Heat	Others
Better
Worse

Pertinent Symptoms

Please indicate if you experienced any of the below:

	Blood clot, deep vein thrombosis or pulmonary embolism		Fingers changing color in the cold or due to stress (white to blue to red)?
	Dry mouth		Glaucoma
	Vaginal dryness		Constipation
	Itchy red skin on sun exposure		Sores in nose or mouth
	Muscle pain		Numbness or tingling
	Swollen lymph nodes or swollen glands		Dry eyes
	Chest pain		Diarrhea
	Shortness of breath		Stroke
	Family history of blood clot or stroke at a young age		Abdominal pain, liver problems, or Hepatitis B/C
	Kidney Failure		Kidney Stones
	Protein in the urine		Diabetes
	Thyroid condition		Cataract
	Miscarriages		Blood clot in artery or vein or pulmonary embolism
	Pain or burning on urination		Urinary retention

Sleep

Do your symptoms disturb your sleep?		Yes		No
Do you get enough sleep at night?		Yes		No
Do you wake up feeling rested?		Yes		No
How many hours do you sleep per night?				hours
Do you work the night shift or alternating day/night shifts?		Yes		No

Tests

Did you have any of the following done? If so, when?

	Date		Date
Chest X-Ray		Colonoscopy
Mammogram		Bone density test
Pelvic exam (women only)		Skin biopsy
PSA (men only)		Rectal exam
Colonoscopy		Kidney biopsy

Vaccines

Pneumonia 13

23 valent

Flu

Pneumonia

Shingles

Hospitalizations

Reason		Year

Surgeries

Type	Reason	Year

Social History

Do you smoke?		Never
		Yes	Packs per Day:		For # Years:
		Past	Year Quit:
Do you exercise regularly?		No		Yes	Amount / week:
Do you drink alcohol?		No		Yes	# Drinks per day:
Did you ever use drugs for reasons that are not medical?				Yes		No
If yes, please list:

Marital Status

	Never Married		Married		Divorced		Separated		Widowed
Spouse/Significant Other:
	Alive/Age:			Deceased/Age:			Major Illness:

Education

Highest level completed: 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade 1st Year of College 2nd Year of College 3rd Year of College 4 Year College
Graduate School:

Family History

	If Living		If Deceased
	Age	Health	Age at Death	Cause
Father
Mother

#of Siblings:		# living:		# deceased:
# of Children:		# living:		# deceased:		List ages:
Health of Children:

	Condition	Who had it?		Condition	Who had it?
	Rheumatoid Arthritis			Psoriasis
	Lupus			Thyroid Disease
	Crohn’s disease			Ulcerative Colitis
	Asthma			Tuberculosis
	Gout			Blood clot in an artery of vein or stroke at young age

Present Medications

Please list any medications you are taking, INCLUDING such items as aspirin, vitamins, laxatives, calcium, herbal supplements, etc.

1		7
2		8
3		9
4		10
5		11
6		12