New Patient History Form

Basic Information

Please let us know your name.

Please write a subject for your message.

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Please write a subject for your message.

Please let us know your email address.

Please write a subject for your message.

Address Information

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Personal Information

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Primary Care Physician

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Emergency Contact

Please let us know your contact's first name.

Please let us know a phone number for your contact.

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Please let us know a cell phone number for your contact.

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Please let us know your relation to the contact.

Please let us know an address for your contact.

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Past Medical History

Please indicate if you have had any of the following conditions

Other Illnesses

Hypertension

Yes No

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High Cholesterol

Yes No

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Hypothyroidism

Yes No

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Other

Yes No

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Diabetes

Yes No

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Heart Disease

Yes No

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Family Members History

Do you have any family members with an autoimmune disorder, gout or osteoarthritis? If so,please list:

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Health Questionnaire

Please complete your health questionnaire to the best of your ability

General

Fever

Yes No

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Chills

Yes No

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Weight Loss

Yes No

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Night Sweats

Yes No

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Hematology

Easy Bruising

Yes No

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Low White Blood Cell Count

Yes No

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Low Platelets

Yes No

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Opthalmologic

Acute Vision Change

Yes No

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Dry Eyes

Yes No

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History of severe painful red eye

Yes No

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Genitourinary

Blood In Urine

Yes No

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ENT

Ringing in Ears

Yes No

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Swollen Glands

Yes No

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Dizziness

Yes No

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Dry Mouth

Yes No

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Difficulty Swallowing

Yes No

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Musculoskeletal

Painful Joints

Yes No

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Muscle Weakness

Yes No

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Swollen Joints

Yes No

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Leg Cramps

Yes No

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Morning Stiffness > 30 min

Yes No

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Muscle Aches

Yes No

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Respiratory

Shortness of breath on the move

Yes No

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Shortness of breath at rest

Yes No

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Cough

Yes No

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Hemoptysis

Yes No

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Psychiatric

Anxiety

Yes No

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Depression

Yes No

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Difficulty Sleeping

Yes No

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Cardiovascular

Chest Pain at Rest

Yes No

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Chest Pain with exertion

Yes No

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Palpitations

Yes No

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Rheumatology

Oral Ulcers

Yes No

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Skin Rash

Yes No

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Headache

Yes No

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Alopecia

Yes No

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Raynaud's

Yes No

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Jaw Claudication

Yes No

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Photosensitivity

Yes No

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Blood Clots

Yes No

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Facial Rash

Yes No

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Miscarriages

Yes No

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Gastrointestinal

Abdominal Pain

Yes No

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Heartburn or Reflux

Yes No

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Nausea

Yes No

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Blood in the Stool

Yes No

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Vomiting

Yes No

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Diarrea

Yes No

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Lifestyle

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Basic Information

Address Information

Personal Information

Primary Care Physician

Emergency Contact

Past Medical History

Other Illnesses

Family Members History

Health Questionnaire

General

Hematology

Opthalmologic

Genitourinary

ENT

Musculoskeletal

Respiratory

Psychiatric

Cardiovascular

Rheumatology

Gastrointestinal

Lifestyle

AUTHORIZATION FOR USE AND DISCLOSURE

Self Paid Patients

Insured Patients

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