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American College of Rheumatology Patient History Form (301893-DT)

American College of Rheumatology Patient History Form (301893-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #

Index to Questionnaire-Health\Encounter

301893-DT (Rev. 12/21/16) AMERICAN COLLEGE OF RHEUMATOLOGY
PATIENT HISTORY FORM Page 1 of 6
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
AMERICAN COLLEGE OF RHEUMATOLOGY
PATIENT HISTORY FORM





Date: _________________________________
MARITAL STATUS: □ Never Married □ Married □ Divorced □ Separated □ Widowed
Spouse/Significant Other: □ Alive/Age ____ □ Deceased/Age _____ Major Illnesses ______________________
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 briefly 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 your or a blood relative had any of the following? (check if “yes)
Yourself Relative
Name/Relationship
Yourself Relative/Name
Relationship
Arthritis (unknown type) Lupus or “SLE”
Osteoarthritis Rheumatoid Arthritis
Gout Ankylosing Spondylitis
Childhood arthritis Osteoporosis
Other arthritis conditions:







Patient Name

DOB:

MR #

Index to Questionnaire-Health\Encounter

301893-DT (Rev. 12/21/16) AMERICAN COLLEGE OF RHEUMATOLOGY
PATIENT HISTORY FORM Page 2 of 6
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
AMERICAN COLLEGE OF RHEUMATOLOGY
PATIENT HISTORY FORM





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 of 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 □ Redness
□ Recent weight loss material □ Rash
amount _________ □ Stomach pain relieved by food or milk □ Hives
□ Fatigue □ Jaundice □ Sun sensitive (sun allergy)
□ Weakness □ Increasing constipation □ Tightness
□ Fever □ Persistent diarrhea □ Nodules/bumps
Eyes □ Blood in stools □ Hair loss
□ Pain □ Black stools □ Color changes of hands or feet in the
□ Redness □ Heartburn cold
□ Loss of vision Genitourinary Neurological System
□ Double or blurred vision □ Difficult urination □ Headaches
□ Dryness □ Pain or burning on urination □ Dizziness
□ Feels like something in eye □ Blood in urine □ Fainting
□ Itching eyes □ Cloudy, “smoky” urine □ Muscle spasm
Ears-Nose-Mouth-Throat □ Pus in urine □ Loss of consciousness
□ Ringing in ears □ Discharge from penis/vagina □ Sensitivity or pain of hands and/or feet
□ Loss of hearing □ Getting up at night to pass urine □ Memory loss
□ Nosebleeds □ Vaginal dryness □ Night sweats
□ Loss of smell □ Rash/ulcers Psychiatric
□ Dryness in nose □ Sexual difficulties □ Excessive worries
□ Runny nose □ Prostate trouble □ Anxiety
□ Sore tongue For Women Only: □ Easily losing temper
□ Bleeding gums Age when periods began: ___________ □ Depression
□ Sores in mouth Periods regular? □ Yes □ No □ Agitation
□ Loss of taste How many days apart? _____________ □ Difficulty falling asleep
□ Dryness of mouth Date of last period? ____/____/____ □ Difficulty staying asleep
□ Frequent sore throats Date of last pap? ____/____/____ Endocrine
□ Hoarseness Bleeding after menopause? □ Yes □ No □ Excessive thirst
□ Difficulty in swallowing Number of pregnancies? ____________ Hematologic/Lymphatic
Cardiovascular Number of miscarriages? ___________ □ Swollen glands
□ Pain in chest Musculoskeletal □ Tender glands
□ Irregular heart beat □ Morning stiffness □ Anemia
□ Sudden changes in heart beat Lasting how long? □ Bleeding tendency
□ High blood pressure _______ Minutes _______ Hours □ Transfusion/when _______________
□ Heart murmurs □ Joint pain Allergic/Immunologic
Respiratory □ Muscle weakness □ Frequent sneezing
□ Shortness of breath □ Muscle tenderness □ Increased susceptibility to infection
□ Difficulty in breathing at night □ Joint swelling
□ Swollen legs or feet List joints affected in the last 6 mos.
□ Cough ________________________________
□ Coughing of blood ________________________________
□ Wheezing (asthma) ________________________________
________________________________
________________________________



Patient Name

DOB:

MR #

Index to Questionnaire-Health\Encounter

301893-DT (Rev. 12/21/16) AMERICAN COLLEGE OF RHEUMATOLOGY
PATIENT HISTORY FORM Page 3 of 6
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
AMERICAN COLLEGE OF RHEUMATOLOGY
PATIENT HISTORY FORM





SOCIAL HISTORY PAST MEDICAL HISTORY

Do you drink caffeinated beverages? Do you now or have you ever had: (check if “yes”)
Cups/glasses per day? _______________________ □ Cancer □ Heart problems □ Asthma
Do you smoke? □ Yes □ No □ Past – How long ago? ______ □ Goiter □ Leukemia □ Stroke
Do you drink alcohol? □Yes □ No Number per week? _____ □ Cataracts □ Diabetes □ Epilepsy
Has anyone ever told you to cut down on your drinking? □ Nervous breakdown □ Stomach ulcers □ Rheumatic fever
□ Yes □ No □ Bad headaches □ Jaundice □ Colitis
Do you use drugs for reasons that are not medical? □ Yes □ No □ Kidney disease □ Pneumonia □ Psoriasis
If yes, please list: __________________________________ □ Anemia □ HIV/AIDS □ High Blood Pressure
__________________________________________________ □ Emphysema □ Glaucoma □ Tuberculosis
Do you exercise regularly? □ Yes □ No Other significant illness (please list) ________________
Type _____________________________________________ _____________________________________________
Amount per week ___________________________________ Natural or Alternative Therapies (chiropractic, magnets,
How many hours of sleep do you get at night? ____________ massage, over-the-counter preparations, etc.)
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? □ No □ Yes Describe: ____________________________________________________________
Any other serious injuries? □ No □ Yes 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 ____________
Health of children: ___________________________________________________________________________________
__________________________________________________________________________________________________
Do you know of any blood relative who has or had: (check and give relationship)
□ Cancer __________ □ Heart disease __________ □ Rheumatic fever __________ □ Tuberculosis __________
□ Leukemia ________ □ High blood pressure _____ □ Epilepsy ________________ □ Diabetes _____________
□ Stroke ___________ □ Bleeding tendency ______ □ Asthma _________________ □ Goiter _______________
□ Colitis ___________ □ Alcoholism ____________ □ Psoriasis ________________






Patient Name

DOB:

MR #

Index to Questionnaire-Health\Encounter

301893-DT (Rev. 12/21/16) AMERICAN COLLEGE OF RHEUMATOLOGY
PATIENT HISTORY FORM Page 4 of 6
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
AMERICAN COLLEGE OF RHEUMATOLOGY
PATIENT HISTORY FORM





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.)
Name of Drug Dose (include
strength & number
of pills per day
How long have
you taken this
medication
Please check: Helped?

A Lot Some Not At All
1. □ □ □
2. □ □ □
3. □ □ □
4. □ □ □
5. □ □ □
6. □ □ □
7. □ □ □
8. □ □ □
9. □ □ □
10. □ □ □
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 medication, results of taking the medication and list any reactions you may have had. Record your comments in the
spaces provided.
Drug names/Dosage Length of
time
Please check: Helped?
A Lot Some Not At All
Reactions
Non-Steroidal Anti-Inflammatory Drugs
(NSAIDS)
□ □ □
Circle any you have taken in the past
Ansaid (flurbiprofen) Arthortec (diclofenac + misoprostol) Aspirin (including coated aspirin) Celebrex (celecoxib) Clinoril (sulindac)

Daypro (oxaprozin) Disalcid (salsalate) Dolobid (diflunisal) Feldene (piroxicam) Indocin (indomethacin) Lodine (etodolac)

Meclomen (meclofenamate) Motrin/Rufen (ibuprofen) Nalfon (fenoprofen) Naprosyn (naproxen) Oruvail (ketoprofen)

Tolectin (tolmetin) Trilisate (choline magnesium trisalicylate) Vioxx (rofecoxib) Voltaren (diclofenac)
Pain Relievers
Acetaminophen (Tylenol) □ □ □
Codeine (Vicodin, Tylenol 3) □ □ □
Propoxyphene (Darvon/Darvocet) □ □ □
Other: □ □ □
Other: □ □ □
Disease Modifying Antirheumatic Drugs (DMARDS)
Auranofin, gold pills (Ridaura) □ □ □
Gold shots (Myochrysine or Solganol) □ □ □
Hydroxychloroquine (Plaquenil) □ □ □
Penicillamine (Cuprimine or Depen) □ □ □
Methotrexate (Rheumatrex) □ □ □
Azathioprine (Imuran) □ □ □
Sulfasalazine (Azulfidine) □ □ □
Quinacrine (Atabrine) □ □ □
Cyclophosphamide (Cytoxan) □ □ □
Cyclosporine A (Sandimmune or Neoral) □ □ □
Etanercept (Enbrel) □ □ □
Infliximab (Remicade) □ □ □
Prosorba Column □ □ □
Other: □ □ □
Other: □ □ □


Patient Name

DOB:

MR #

Index to Questionnaire-Health\Encounter

301893-DT (Rev. 12/21/16) AMERICAN COLLEGE OF RHEUMATOLOGY
PATIENT HISTORY FORM Page 5 of 6
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
AMERICAN COLLEGE OF RHEUMATOLOGY
PATIENT HISTORY FORM





PAST MEDICATIONS Continued
Osteoporosis Medications
Estrogen (Premarin, etc.) □ □ □
Alendronate (Fosamax) □ □ □
Etidronate (Didronel) □ □ □
Raloxifene (Evista) □ □ □
Fluoride □ □ □
Calcitonin injection or nasal (Miacalcin,
Calcimar)
□ □ □
Risedronate (Actonel) □ □ □
Other: □ □ □
Other: □ □ □
Gout Medications
Probenecid (Benemid) □ □ □
Colchicine □ □ □
Allopurinol (Zyloprim/Lopurin) □ □ □
Other: □ □ □
Other: □ □ □
Others
Tamoxifen (Nolvadex) □ □ □
Tiludronate (Skelid) □ □ □
Cortisone/Prednisone □ □ □
Hyalgan/Synvisc injections □ □ □
Herbal or Nutritional Supplements □ □ □
Please list supplements:


Have you participated in any clinical trials for new medications? □ Yes □ No
If yes, list:







Patient Name

DOB:

MR #

Index to Questionnaire-Health\Encounter

301893-DT (Rev. 12/21/16) AMERICAN COLLEGE OF RHEUMATOLOGY
PATIENT HISTORY FORM Page 6 of 6
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
AMERICAN COLLEGE OF RHEUMATOLOGY
PATIENT HISTORY FORM





ACTIVITIES OF DAILY LIVING
Do you have stairs to climb? □ Yes □ No If yes, how many? ______________________
How many people in household? _________ Relationship and age of each _____________________________________
Who does most of the housework? _______ Who does most of the shopping? ________ Who does most of the yard work? ________
On the scale below, circle a number which best describes your situation; Most of the time, I function…

1 2 3 4 5

VERY
POORLY
POORLY OK WELL VERY
WELL

Because of health problems, do you have difficulty:
(Please check the appropriate response for each question.)

Usually Sometimes No
Using your hands to grasp small objects? (buttons, toothbrush, pencil, etc.).………………………………… □ □ □
Walking? ....................................................................................................................................................... □ □ □
Climbing stairs? ……………………………………………………………………………………………………… □ □ □
Descending stairs? ………………………………………………………………………………………………….. □ □ □
Sitting down? ………………………………………………………………………………………………………… □ □ □
Getting up from chair? ……………………………………………………………………………………………… □ □ □
Touching your feet while seated? …………………………………………………………………………………. □ □ □
Reaching behind your back? ………………………………………………………………………………………. □ □ □
Reaching behind your head? ………………………………………………………………………………………. □ □ □
Dressing yourself? …………………………………………………………………………………………………... □ □ □
Going to sleep? ……………………………………………………………………………………………………… □ □ □
Staying asleep due to pain? ……………………………………………………………………………………….. □ □ □
Obtaining restful sleep? …………………………………………………………………………………………….. □ □ □
Bathing? ……………………………………………………………………………………………………………… □ □ □
Eating? ……………………………………………………………………………………………………………….. □ □ □
Working? ……………………………………………………………………………………………………………... □ □ □
Getting along with family members? ……………………………………………………………………………… □ □ □
In your sexual relationship? ………………………………………………………………………………………... □ □ □
Engaging in leisure time activities? ……………………………………………………………………………….. □ □ □
With morning stiffness? …………………………………………………………………………………………….. □ □ □
Do you use a cane, crutches, a walker or wheelchair? (circle one) …………………………………………… □ □ □
What is the hardest thing for you to do? ____________________________________________________________________________
Are you receiving disability? ……………………………………………………………………………………….. □ Yes □ No
Are you applying for disability? …………………………………………………………………………………….. □ Yes □ No
Do you have a medically related lawsuit pending? ……………………………………………………………… □ Yes □ No
















Patient History Form © 1999 American College of Rheumatology

Signature of Patient/Representative _________________________________Date: __________Time: _____________AM
PM

If signed by person other than the patient, print name and state relationship and authority to do so.


Print Name: _____________________________________Relationship: __________________________________

Patient is:  Minor  Incompetent / Incapacitated
Legal Authority:  Legal Guardian  Parent of Minor
 Health Care Agent  Other _____________________


Reviewed by: ___________________________________________________ Date: ______________ Time: _____________ AM
PM