Rheumatologyassociatesofhouston.com

PATIENT QUESTIONNAIRE
Patient Name: ________________________________________________________ DOB: ______________________ Age: _________ Family or Internal Medicine Physician: ______________________________________________ Today’s Date: _____________________ HISTORY OF PRESENT ILLNESS
Describe present symptoms: _____________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Have you seen other physicians for this problem? q YES q NO Have you had studies and/or labs performed to evaluate for this problem? q YES q NO Have you or a blood relative had any of the following?
2010 Naomi Street, Suite A • Houston, Texas 77054 RAH-206 A Phone 713.667.8292 • FAX 713.667.8925 Continued from front page:
Other family history: (Describe relationship to blood relative and disease) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ PAST MEDICAL HISTORY
Serious injuries:
Any history of broken bones:
Surgical History:
WOMAN ONLY
Are you still having regular menstrual periods? q YES q NO Age of menopause onset? ___________________ SOCIAL HISTORY
Occupation: _________________________ Martial Status: q S q M q D q W Age of Children: ___________
Ethnicity:
q African-American q Asian q Caucasian q Hispanic q Native American/Alaskan Native q Other Smoking History: q YES q NO
Age Started: _______ Packs/day: _______ Quit? How Long? ________ Alcohol use: q YES q NO
How much alcohol do you consume per day? ___________________________ Any history of intravenous (injection) drug use? q YES q NO TRAVEL HISTORY
Immigrant:
Country _______________________________________ International Travel Past 3 years:
Country _______________________________________ Any HIV/AIDS risk factors? q YES q NO (homosexuality, multiple sexual partners, history of sexually transmitted disease, unprotect- ed intercourse with individuals at risk, injecting drug users, all recipients of blood, blood products or organ transplants between 1978 and 1985) Do You Exercise? q YES q NO Frequency/week: __________________ Type of exercise: _____________
Sleep Habits: Hours of sleep at night: _______________
Insomnia? q YES q NO If yes, describe: ______________________________________ Do you wake up feeling rested? q YES q NO Result _________________________________________ Do You Require use of any of the following: q Cane q Walker q Wheelchair q Scooter MEDICATIONS
Medication Allergies:
Present: List any medications you are taking at this time. Include over the counter, vitamins, supplements
Dosage (include strength and times per day) Past: Please review this list of “arthritis” medications. As accurately as possible, try to remember which medications you have
taken, the results of taking the medication, and list any reactions you may have had.
2010 Naomi Street, Suite A • Houston, Texas 77054RAH-206 C Phone 713.667.8292 • FAX 713.667.8925

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