THE CONSULTANT GROUP, P.C. RHEUMATOLOGY NEW PATIENT QUESTIONNAIRE
NAME:____________________________________________________
BIRTHDATE: ___ RACE: __ ____SEX:M F___ RIGHT HANDED( )LEFT HANDED( ) NAME OF PHYSICIAN WHO REFERRED YOU:_______________________________________ ADDRESS:__________________________________________________________________
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PHONE: (___)_________________ NAME OF YOUR FAMILY PHYSICIAN:____________________________________________ ADDRESS:__________________________________________________________________
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PHONE: (___)_________________ THE MAIN PROBLEM YOU ARE HAVING:__________________________________________
HOW LONG HAVE YOU BEEN HAVING THIS PROBLEM:_______________________________ HAVE YOU PREVIOUSLY SEEN A RHEUMATOLOGIST? ( ) NO ( ) YES
IF SO, WHO, WHEN, WHERE:________________________________________________ PLEASE CHECK (v) IF YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING PROBLEMS:
( ) BLOODY STOOLS ( ) ULCERS ( ) IRRITATED COLON PAST MEDICAL HISTORY: PLEASE CHECK IF YOU HAVE HAD ANY OF THE FOLLOWING PROBLEMS:
( ) HEART DISEASE/HEART MURMURS ( ) JAUNDICE/HEPATITIS ( ) STROKE ( ) HIGH BLOOD PRESSURE
( ) KIDNEY DISEASE/KIDNEY STONES ( ) DIABETES
( ) SYSTEMIC LUPUS ERYTHEMATOSUS ( ) OSTEOARTHRITIS
( ) OTHER ______________________________________________________________
HAVE YOU EVER HAD A BLOOD TRANSFUSION? ( ) NO ( ) YES
IF SO, WHAT YEAR(S): _____________________________________________
IF SO, DESCRIBE:__________________________________________________
IF SO, DESCRIBE:__________________________________________________
# PREGNANCIES: # LIVE BIRTHS: # MISCARRIAGES:_________ OVER
MEDICATIONS: LIST ALL MEDICINES YOU ARE ALLERGIC TO:
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LIST ALL MEDICINES YOU ARE CURRENTLY TAKING (con
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PAIN MEDS/NARCOTICS PRESCRIPTIONS WILL NOT BE REFILLED AFTER BUSINESS HOURS
PLEASE CIRCLE WHETHER OR NOT YOU HAVE EVER TAKEN THE FOLLOWING MEDICINES:
(Y) (N) CORTISONE/PREDNISONE (Y) (N) TOLECTIN
(Y) (N) ANY MEDICINE W/ASPIRIN (Y) (N) CELEBREX
SOCIAL HISTORY: HAVE YOU EVER SMOKED? HOW MUCH? _______________________
FOR HOW MANY YEARS: IF YOU QUIT, HOW LONG AGO? ________________
HAVE YOU EVER TAKEN IV DRUGS/ILLICIT DRUGS? ( ) NO ( ) YES
DO YOU DRINK ALCOHOL? HOW MUCH? _________________________________
FOR HOW MANY YEARS: IF YOU QUIT, HOW LONG AGO? ________________
DO YOU DRINK COFFEE? ( ) NO ( ) YES IF SO, HOW MUCH?
ARE YOU EMPLOYED OUTSIDE THE HOME? ( ) NO ( )
IF SO, WHAT DO YOU DO? __________________________________________________
HOW MANY HOURS A WEEK? _____________________
ARE YOU ON DISABILITY? ( ) NO ( ) YES WERE YOU ADOPTED? ( ) NO ( ) YES
IF YOU HAVE ANY HOBBIES, WHAT ARE THEY? _________________________________ _________________________________________________________________________
EDUCATION:GRADE SCHOOL____, HIGH SCHOOL____, COLLEGE____, POST GRADUATE____
FAMILY HISTORY:
Mother: _____ Y N ______ __________________________ _______________ Father: _____ Y N ______ __________________________ _______________ Sister: _____ Y N ______ __________________________ _______________ Sister: _____ Y N ______ __________________________ _______________ Brother: _____ Y N ______ __________________________ _______________ Brother: _____ Y N ______ __________________________ _______________
HAS ANYONE IN YOUR FAMILY EVER HAD THE FOLLOWING PROBLEMS: ( ) NO ( ) YES ARTHRITIS
( ) NO ( ) YES ANKYLOSING SPONDYLITIS ( ) NO ( ) YES CANCER/LEUKEMIA ( ) NO ( ) YES OSTEOPOROSIS
g:shared/medical records/forms/rheum np ?naire Revised 11/2004
SPAIN F20 FUTURES - MARTOS 14 Jun 2011 - 19 Jun 2011 Last Updated: 31 May 2011 Main Draw Date of Birth Ranking Prot'd Information Priority Main Draw Wild Cards Date of Birth 64 Qualifying Date of Birth Ranking Prot'd Information Priority Rank Date: 23 May 2011 All players who compete in ITF Pro Circuit tournaments must have a valid IPIN and sign-up
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