PATIENT MEDICAL HISTORY PATIENT INFORMATION Name: __________________________________________________________________________________ Referred here by:
Self
Family
Friend
Doctor
Other Health Professional
If Doctor, please give name & address: ___________________________________________________________ ________________________________________________________________________________________ List doctors seen in the last 24 months: __________________________________________________________ Relative(s) to get in touch with in case of emergency: 1. Name:
______________________________________________________________________________
Address: ______________________________________________________________________________ _______________________________________________ Phone Number: __________________ 2. Name:
______________________________________________________________________________
Address: ______________________________________________________________________________ ______________________________________________ Phone Number: __________________ HISTORY OF PRESENT ILLNESS What symptoms are you having which prompted you to seek a consultation with the SIMED Arthritis Center? _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Please list previous treatment for this problem (include physical therapy, surgery and/or injections (medications to be listed later)). __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ PAST MEDICAL HISTORY Do you have any allergies to or problems with medications? (If so, please list the medicine, the type of reaction (rash, nausea, low blood pressure, trouble breathing, etc…) and when the episode occurred). _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Do you have any known food allergies? (If so, please list the foods and the reaction noted). ____________________ ________________________________________________________________________________________
SIMEDHEALTH ARTHRITIS CENTER
Tina Brar, MD • Meghavi Kosboth, DO • T. Mark Lloyd, MD Miguel Rodriguez, MD • Donald Scott, MD • Michael Rozboril, MD P: 352-378-5173 • F: 352-375-2330 4343 Newberry Road, Suite 8, Gainesville, FL 32607 SIMEDHealth.com
Name: ____________________________________________________________________________________ PAST MEDICAL HISTORY (CONT’D) Have you ever had any surgical procedure(s) performed? (If so, please list the procedure, the reason performed, the hospital and date performed and the surgeon’s name – if possible) Procedure Reason Location/Date Surgeon Performed 1. 2. 3. 4. 5. Do you have at present (or have you ever had) any known medical problems for which you have been followed and treated by a physician (for example, high blood pressure, diabetes, heart problems, gout, etc…) Medical problem Year Diagnosed Years Treated 1. 2. 3. 4. 5. 6. Have you ever been hospitalized for something other than a surgical procedure? (If so, for what reason, when/where, and under the care of whom?) Reason When/Where Attending Physician 1. 2. 3. 4. 5. MEDICATIONS Has it Helped? Name of Drug Dose Length Taken A Lot Some None 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. PERSONAL HABITS Do you consume alcoholic beverages? Yes No If so, approximately how much per day? _________________ Do you use tobacco products?
Yes No If so, what type, for how long, and how much? _______________
How many hours do you work per week? _______ Hrs. Do you consider your work:
Satisfying
Stressful
Excessively Tiring
What other jobs have you held during your lifetime? _________________________________________________ __________________________________________________________________________________________ Do you exercise? Yes No If so, what type of exercise and how much? ______________________________ __________________________________________________________________________________________ How many hours of sleep do you get per night? ___________
Do you feel rested when you awaken? Yes No SIMEDHEALTH ARTHRITIS CENTER
SIMEDHealth.com
Name: _________________________________________________________________________________ FAMILY MEDICAL HISTORY Please list age now, (or at the time of death), state of health or cause of death, for the following family members: If Living If Deceased Age Health (such as cancer, diabetes, Age Cause bleeding) Mother Maternal Grandmother Maternal Grandfather Father Paternal Grandmother Paternal Grandfather Brothers/Sisters (Indicate sex) M / F M / F M/ F M/ F Children
□ Son / □ Daughter □ Son / □ Daughter □ Son / □ Daughter □ Son / □ Daughter
Spouse Grade School College 1
EDUCATION (Check highest level attended) Junior High School 7 8 9 High School 2
3 4
10
11 12
Graduate School _____________________________
HOME CONDITIONS On the scale below, check the number which best describes your situation; most of the time I function: 1 Very Poorly 2 Poorly 3 Okay 4 Well
Very Well
What is the hardest thing for you to do physically?
Are you receiving Disability? Yes No Are you applying for Disability? Do you have a medically-related lawsuit pending? Yes No
Yes No
SIMEDHEALTH ARTHRITIS CENTER
SIMEDHealth.com
Name: _________________________________________________________________________________ REVIEW OF SYSTEMS Please mark any problems you have or have had in these areas: HEENT GU ENDOCRINE Cataract
Nephritis
Thyroid Disease
Glaucoma
Kidney Infection
Diabetes
Migraine Headaches
Syphilis
HEMA/ONC
Sinus Infections
Gonorrhea
Any Kind of Cancer (Type__________)
HEART
Genital Herpes
Anemia
Rheumatic Fever
MS
Blood Transfusion
Heart Attack
Rheumatoid Arthritis
Blood Clots
Angina
Gout
Bleeding Tendency
Heart Failure
Lupus
OTHER
Heart Palpitations
Serious Joint Injury
Alcoholism
High Blood Pressure
Broken Bones
Drug Abuse
LUNG
Disabling Back Pain
AIDS/HIV
Asthma
Degenerative Arthritis
Other _______________________
Pneumonia
Osteoporosis
WOMEN ONLY
Pleurisy
SKIN
Pregnancy (# of times_______________)
Blood Clot in Lung Tuberculosis
Skin Ulcer – Lower Leg
Miscarriage (# of times______________)
Fingers Turning White
Toxemia / Eclampsia
GI
Psoriasis
Stomach / Duodenal Ulcer
NEURO/PSYCH
Cirrhosis
Meningitis
Hepatitis
Stroke / Paralysis
Gallstones
Seizure / Epilepsy
Pancreas Disease
Depression
Intestinal Polyp
Nervous Breakdown
Esophagus Disease Colitis Diverticulitis Diarrhea
SIMEDHEALTH ARTHRITIS CENTER
SIMEDHealth.com
Name: _________________________________________________________________________________ REVIEW OF SYSTEMS (Cont’d) Please mark any problems you have or have had in these areas: GENERAL
CARD/PULM
MS / NEURO
Weight Gain
Chronic Cough
Joint Pain
Weight Loss
Coughing Up Blood
Joint Swelling
Poor Appetite
Shortness of Breath
Stiff Muscles
Fever, Chills, Sweats
Chest Pain
Painful Muscles
Swollen Glands
GI
Weak Muscles
New Lump or Growth
Heartburn
Numbness
Feeling Fatigue
Nausea and/or Vomiting
SKIN
Trouble Sleeping
Stomach/Abdominal Pain
Rash
Problems with the Sun
Constipation
Skin Ulcers
Hair Loss
Diarrhea
Bumps On Skin
Hair Overgrowth
Bleeding From Rectum
Tick Bites
HEENT
Black Bowel Movement
Loss of Vision
GU
Dry Eyes
Problems Passing Urine
Redness in Eyes
Urine Leak
Headaches
Blood In Urine
Ringing in Ears
Burning on Urination
Loss of Hearing
Discharge From Penis
Nasal Congestion
Discharge From Vagina
Dry Mouth
Sores on Genitals
Trouble Swallowing
Menstrual Problems
Mouth Sores / Ulcers
I May Be Pregnant
Recent Tooth Pulled
Breast Lump
Hoarseness
SIMEDHEALTH ARTHRITIS CENTER
SIMEDHealth.com
Suite 8 – SIMEDHealth Arthritis Center (Rheumatology)
Dark Green – First Floor Light Green – Ground Floor
PARKING LOT
4343 W Newberry Road, Gainesville, FL 32607 (352) 378-5173 | SIMEDHealth.com
S COVERED DRIVE-THRU
W
1 N
2a
2b
PHARMACY
MAIN LOBBY
Enter South entrance into main lobby
2
Take stairs or elevator up to 1st floor
3
Once on 1st floor, take right, then left into hall
4
Enter Suite 8 on right
NEWBERRY ROAD
43RD STREET
1
Your Destination
COURTYARD
NORTH ENTRANCE
4
COURTYARD
Suite 8 Arthritis Center
3
PARKING LOT
E
