NEW PATIENT QUESTIONNAIRE - Saint Luke`s Health System

Saint Luke’s Cushing Hospital
Rheumatology Medicine
New Patient Questionnaire
Name _______________________________________ Date __________________________
Date of Birth ______________________ Age _________ Referring Dr. ________________
Height _______ Weight _______
History of Present Illness:
Reason for Visit _________________________________________________________________________________
Do you have pain? Yes
No Where is your pain located? Please mark
your pain on the diagram.
When did it start? _______________ Was it due to an accident? Yes No
How long does it last? _____________________________________________
How often does it occur? ___________________________________________
What relieves the pain? ____________________________________________
What aggravates the pain? __________________________________________
What kind of pain is it? (Deep, Sharp, Dull, Burning, etc.)
What is the intensity of the pain? (0-10, 0=none, 10=worst ever)
Now _______ At best _______ At worst _______
Do you have any numbness, tingling, or weakness? Yes
No (Circle)
What tests have been done? (X-ray, EMG, MRI, CT scan)________________________________________________
Have you had any prior treatment? (therapy, injections, surgeries) __________________________________________
General Health Review
Medical History (such as heart disease, stroke, cancer, arthritis, diabetes, hypertension, psychiatric illnesses, etc.; list
____________________________ _____________________________ ________________________________
____________________________ _____________________________ ________________________________
Surgical History: (list dates)
____________________________ _____________________________ ________________________________
____________________________ _____________________________ ________________________________
Medication Allergies: (rashes- difficulty breathing)
____________________________ _____________________________ ________________________________
Intolerances: (include side effects from previous medications, such as gastritis, nausea, constipation, etc.)
____________________________ _____________________________ ________________________________
Page 1 of 2
Trial form (09/28/10)
Saint Luke’s Cushing Hospital
Rheumatology Medicine
New Patient Questionnaire
Current Medications: (include vitamins and birth control pills, if applicable)
See medication reconciliation form
Social History/Functional History:
Do you currently work outside of the home? Yes
No Occupation: ___________________________________
What type of recreational activities do you do? _________________________________________________________
Do you live by yourself? Yes
Marital Status? ___________________
Home or Apartment? __________________ How many levels? ______________ How many stairs? ______________
Do you use:
bedside commode
tub grab bars
Smoking History: How much? _______________ How long? _____________ ___Have you quit? Yes
How often do you drink alcohol? _____________________ How much?_____________________
Caffeine: Coffee_____________ Tea______________ Soda______________ How often_________________
Family History: ↑Living ↓Deceased (please circle)
Mother ↑ ↓ Diseases ______________________________________________________ Age __________________
Father ↑ ↓ Diseases ______________________________________________________ Age __________________
Brothers ↑ ↓ Diseases ______________________________________________________Ages _________________
Sisters ↑ ↓ Diseases _______________________________________________________ Ages _________________
Children How many? _______ ↑ ↓ Diseases ___________________________________ Ages _________________
Review of Systems:
Circle any that apply or NA = not applicable
General (weight changes ↑ ↓ ____ lbs., fever, chills, night sweats, insomnia, appetite, NA)
SKIN (rashes, color changes, bruising, bleeding, pigmentations, sores, NA)
HEAD (headaches, trauma, NA)
EYES (reading, visual fields, disturbances, NA)
EARS (hearing, infections, discharge, NA)
NOSE (sinus problems, smell, NA)
MOUTH AND TEETH (teeth: exams, sore throat, swallow, drooling, NA)
NECK (lumps, pain, limitation of movement, trauma, circulation, NA)
BREASTS (lumps, surgery, pain, discharge, NA)
RESPIRATORY (cough, asthma, shortness of breath, painful breathing, NA)
CARDIAC (chest pain, heart attack, palpitations, edema, murmurs, hypertension, NA)
GASTROINTESTINAL (nausea, vomiting, bleeding, diarrhea, constipation, incontinence)
MUSCULO (weakness, arthritis, gout, pain, trauma, scoliosis, back problems, surgeries, cramps, NA)
VASCULAR (vein problems, grafts, DVT, leg clots, NA)
NEURO (seizures, weakness, paralysis, numbness, tingling, balance, speech, cognition, NA)
PSYCH (depression, anxiety, hallucinations, psych care, NA)
ENDOCRINE (heat/cold intolerance, osteoporosis, NA)
HEMOTOLOGY (anemia, immune problems, clotting, bleeding, blood thinners, NA)
Page 2 of 2
Trial form (09/28/10)