Rheumatology Consultation Referral Form
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CLINICAL HISTORY FORM TODAY’S DATE: NAME: DATE OF BIRTH: CHIEF COMPLAINT JOINT PAIN JOINT SWELLING FATIGUE WEAKNESS DECREASED MOBILITY RASHES STIFFNESS FEVER OTHER: WHERE? HOW LONG HAVE YOU HOW DOES IT FEEL? WORSE WITH: “ALL OVER” HAD THIS PROBLEM? ACHY SITTING ALL JOINTS BURNING STANDING MANY JOINTS IS THE PROBLEM: DULL WALKING ALL MUSCLES GRADUAL SHARP OVER EXERTION MANY MUSCLES INTERMITTENT SHOOTING STANDING UP JAWS SUDDEN THROBBING STRESS CHEST FREQUENT TINGLY PREMENSTRUAL PERIOD NECK CONSTANT NUMB COLD WEATHER MID BACK COME AND GO HOT WET WEATHER LOWER BACK TIMING? OTHER: OTHER: LT RT SHOULDERS MORNING LT RT ELBOWS AFTERNOON HOW LONG IS YOUR BETTER WITH: LT RT WRISTS EVENING MORNING STIFFNESS? HEAT LT RT HANDS NIGHT < 10MIN ICE LT RT FINGERS SEVERITY? > 15MIN REST LT RT HIPS MILD > 30MIN STRETCHING LT RT KNEES MODERATE > 60MIN SHOWER/BATH LT RT ANKLES SEVERE > 90MIN ACTIVITY LT RT FEET CHANGES IN INTENSITY > 2 HRS MASSAGE LT RT TOES OTHER: CURRENT PRESCRIPTION MEDICATIONS MEDICATION NAME STRENGTH QUANTITY TAKEN TIMES PER DAY (EXAMPLE) PREDNISONE 5 MG 2 TABLETS 3 TIMES PER DAY OVER THE COUNTER MEDICATIONS/NUTRITIONAL SUPPLEMENTS/VITAMINS MEDICATION NAME STRENGTH QUANTITY TAKEN TIMES PER DAY PAST MEDICAL HISTORY RESPIRATORY: OB/GYN & GENITOURINARY: ASTHMA PROSTATE DISEASE MUSCULOSKELETAL: EMPHYSEMA INFERTILITY ANKYLOSING SPONDYLITIS COPD POLYCYSTIC OVARIAN DISEASE SCOLIOSIS PNEUMONIA CHRONIC UTI SCIATICA SLEEP APNEA # OF PREGNANCIES: CERVICAL DISC DISEASE TB # OF MISCARRIAGES: LUMBAR DISC DISEASE SINUS/ALLERGIES # OF LIVING CHILDREN: LOW BACK PAIN BRONCHITIS MENOPAUSE AGE: TMJ INTERSTITIAL LUNG DISEASE EUROLOGICAL VASCULITIS N : ERMATOLOGY BELLS PALSY CARPAL TUNNEL D : HAIR LOSS GUILLIAME BARRE BEHCET’S ECZEMA PARKINSONS RAYNAUDS CHRONIC HIVES POLIO NEUROMAS PSORIASIS STROKE OSTEOPOROSIS SEIZURES OSTEOPENIA ENDOCRINE: MIGRAINES LOW VITAMIN D DIABETES MULTIPLE SCLEROSIS RHEUMATOID ARTHRITIS HIGH CALCIUM PERIPHERAL NEUROPATHY PSORIATIC ARTHRITIS THYROID DISEASE OSTEOARTHRITIS ANKLE/FOOT OVERACTIVE THYROID INFECTIOUS DISEASES: OSTEOARTHRITIS HAND UNDERACTIVE THYROID HEPATITIS: A B C OSTEOARTHRITIS HIP OPHTHALMOLOGY: ABSCESSES OSTEOARTHRITIS KNEE IRITIS BACTERIAL ENDOCARDITIS OSTEOARTHRITIS SHOULDER SCLERITIS CELLULITIS OSTEOARTHRITIS NECK BLINDNESS HIV/AIDS OSTEOARTHRITIS THORACIC CATARACTS MALARIA OSTEOARTHRITIS LUMBAR GLAUCOMA SHINGLES POLYMYALGIA RHEUMATICA DIABETIC RETINOPATHY TUBERCULOSIS FIBROMYALGIA RETINAL HEMORRHAGE OSTEOMYELITIS LUPUS RETINAL DETACHMENT PSYCHOLOGICAL: PLANTAR FASCIITIS GASTROINTESTINAL: BIPOLAR DISORDER BUNIONS ESOPHAGEAL STRICTURE PERSONALITY DISORDER GOUT BARRETT’S ESOPHAGUS OBSESSIVE COMPULSIVE COSTOCHONDRITIS GERD DISORDER POLYMYOSITIS CELIAC DISEASE POST-TRAUMATIC STRESS SCLERODERMA GI BLEEDING DEPRESSION DERMATOMYOSITIS IRRITABLE BOWEL PANIC ATTACKS ROTATOR CUFF DISEASE COLON POLYPS SCHIZOPHRENIA TEMPORAL ARTERITIS CIRRHOSIS HEMATOLOGY/ONCOLOGY: NON TRAUMATIC BONE DIVERTICULOSIS IRON DEFICIENT ANEMIA FRACTURE DIVERTICULITIS B12 DEFICIENT ANEMIA CARDIOLOGY: ULCERS ANEMIA - ALL OTHERS ATRIAL FIBRILLATION ULCERATIVE COLITIS OVARIAN CANCER CHF CROHN’S COLITIS PROSTATE CANCER HIGH BLOOD PRESSURE KIDNEY: COLON CANCER HTN RENAL CYST BREAST CANCER HEART MURMUR RENAL INSUFFICIENCY LUNG CANCER HEART ATTACKS DIABETIC KIDNEY DISEASE KIDNEY CANCER PERICARDITIS KIDNEY STONE PANCREATIC CANCER PERIPHERAL VASCULAR DISEASE KIDNEY FAILURE LYMPHOMA HIGH CHOLESTEROL LEUKEMIA HIGH TRIGLYCERIDES SKIN MELANOMA OTHER PERTINENT MEDICAL HISTORY: ALLERGIES/ADVERSE REACTIONS FAMILY HISTORY WHO?? MEDICATION/ALLERGY REACTION ANKYLOSING SPONDYLITIS DERMATOMYOSITIS OSTEOARTHRITIS POLYMYALGIA RHEUMATICA SCIATICA BEHCET'S SYNDROME FIBROMYALGIA OSTEOPOROSIS PSORIATIC ARTHRITIS SYSTEMIC LUPUS ERYTHMATOSIS SJOGRENS SYNDROME GOUT PLANTAR FASCIITIS SURGERIES WHEN? RHEUMATOID ARTHRITIS TEMPORAL ARTERITIS CATARACTS DEGENERATIVE DISC DISEASE THYROID HERNIATED DISC TONSILS POLYMYOSITIS CARPAL TUNNEL SCLERODERMA SKIN CANCERS VASCULITIS APPENDIX HIP FRACTURE PROSTATE BLADDER REPAIR SOCIAL HISTORY GALLBLADDER MARITAL STATUS: SINGLE MARRIED BUNIONECTOMY WIDOW DIVORCED CERVICAL DISK EDUCATION: SOME HIGH SCHOOL GED LUMBAR DISK HIGH SCHOOL DIPLOMA GASTRECTOMY SOME COLLEGE DEGREE DIVERTICULITIS/COLON EMPLOYMENT: STUDENT HOMEMAKER HEMORRHOIDS RETIRED UNEMPLOYED GASTRIC BYPASS PART TIME FULL TIME HIATAL HERNIA HEART WHAT JOB DO YOU DO? PACEMAKER IF YOU ARE NOT WORKING NOW, HEART BYPASS WHEN DID YOU LAST WORK? STENTS DO YOU CONSIDER YOURSELF DISABLED? YES NO VALVE REPLACEMENT ARE YOU RECEIVING SS DISABILITY? YES NO ARTHROSCOPIC KNEE: L R AS OF WHAT DATE?: TOTAL HYSTERECTOMY PARTIAL HYSTERECTOMY HAVE YOU LIVED IN: AZ, AR, CA, IL, IN, IA, KY, LA, MN, MS, # OF OVARIES REMOVED: 1 2 MO, NM, OH, PA, UT, WV, WI? O YES O NO HIP REPLACEMENT: L R WHERE HAVE YOU TRAVELED OUTSIDE THE USA? SHOULDER REPLACEMENT: L R KNEE REPLACEMENT: L R TOBACCO USE: NEVER CURRENT PREVIOUS OTHER: # OF PACKS PER DAY: 1/2 PACK 1 PACK 2 PACKS YEARS USED? IMMUNIZATIONS/VACCINATIONS IF YOU QUIT, HOW LONG AGO? ALCOHOL USE: NEVER CURRENT PREVIOUS HEPATITIS B RECEIVED: # OF DRINKS: 1 2 3 >3 SHINGLES RECEIVED: PER: DAY WEEK MONTH PNEUMONIA RECEIVED: ILLEGAL DRUG USE: NEVER CURRENT PREVIOUS INFLUENZA RECEIVED: ARE YOU CURRENTLY, OR HAVE YOU PREVIOUSLY SEEN A PPD/TB TESTING RECEIVED: PAIN MANAGEMENT PHYSICIAN? NO YES OTHER RECEIVED: WHO? DIAGNOSTIC TESTING HAVE YOU HAD ANY OF THE FOLLOWING? WHEN? WHERE? BONE DENSITY SCAN MRI CT SCAN LABWORK ADDITIONAL INFORMATION WHAT TREATMENTS OR GENERAL: GASTROENTEROLOGY: PSYCHOLOGY: MEDICATIONS HAVE YOU RATE YOUR LOSS OF APPETITE ANXIETY TRIED IN THE PAST? DAYTIME ENERGY: HEMORRHOIDS DEPRESSION ASPIRIN 0=FULL ENERGY,10=EXHAUSTED NAUSEA TROUBLE SLEEPING TYLENOL CHILLS HEARTBURN HARD TO GET TO SLEEP ADVIL FATIGUE VOMITING HARD TO STAY ASLEEP ALEVE FEVER DIARRHEA DO YOU NAP? YES NO PAIN MEDS NIGHT SWEATS CONSTIPATION MUSCLE RELAXERS WEIGHT GAIN CHANGE IN BOWEL WHAT WAKES YOU FROM PHYSICAL THERAPY WEIGHT LOSS BLOOD IN STOOL SLEEP? WATER THERAPY SPOUSE EXERCISES OPTHALMOLOGY: HEMATOLOGY/LYMPH: CHILDREN OTHER: EYE PAIN EASY BLEEDING SNORING ITCHY EYES TENDER GLANDS BURNING FEET DOUBLE VISION SWOLLEN GLANDS PAIN HAT TREATMENTS W RED EYES HEADACHES OR MEDICATIONS VISION LOSS DERMATOLOGY: HEARTBURN HAVE WORKED BEST? DRY EYES NUMB HANDS HAIR LOSS FULL BLADDER OPEN WOUNDS OR SORES CHOKING ENT: RASH STIFFNESS SINUS INFECTION EAR PAIN INTEGUMERY: MOUTH SORES RATE YOUR SLEEP: BLUE OR WHITE FINGERS XCELLENT OOR TASTE/SMELL LOSS 0=E , 10=P WHICH HAND IS RATE YOUR MORNING STUFFY NOSE DOMINANT? GENITOURINARY: RESTED-NESS: TROUBLE CHEWING RIGHT LEFT BLOOD IN URINE 0=RESTED, 10=EXHAUSTED DRY MOUTH INCONTINENCE RATE YOUR EMOTIONAL HEARING LOSS HARDWARE /METAL INTIMACY ISSUES STRESS: RINGING IN EARS IN BODY: PAINFUL GENITAL ULCER 0=NONE, 10=SEVERE ANEURYSM CLIPS RECURRENT UTI RESPIRATORY: ANY OTHER ISSUES: AORTIC CLIPS WHEEZING COCHLEAR IMPLANTS NEUROLOGY: TB – OR EXPOSURE HEARING AID BURNING FEET SHORTNESS OF BREATH NEUROTRANSMITTER POOR CONCENTRATION COUGH PROSTHESIS FREQUENT FALLS INSULIN PUMP LOSS OF BALANCE CARDIOLOGY: FRACTURED BONES RATE MEMORY: W/RODS,PLATES, SWOLLEN LEGS/FEET 0=EXCELLENT,10=VERY POOR SCREWS, NAILS CHEST PAIN HEADACHE OR CLIPS DIZZINESS TINGLING/NUMBNESS METAL SLIVERS IN EYES PALPITATIONS TREMOR SHRAPNEL MEMORY LOSS .