Isa patient hx

Midwest Orthopaedic Institute
Rheumatology Patient History Form

Name: __________________________

Date: ________________

Please fill out and/or circle your answer. Please skip what does not apply to you. Thank you.

If yes, please circle where you have pain: Right side: fingers. Wrist. Elbow. Shoulder. Hip. Knee. Ankle. Toes. Left Side: fingers. Wrist. Elbow. Shoulder. Hip. Knee. Ankle. Toes. Neck. Mid back. Low back. Arm muscles. Leg muscles. Others: ________________ Aching. Burning. Stabbing. Crampy. Electric shock. Pins & Needles. Pulling 3. When did your symptoms start? ___ Days. ___Weeks. ____ Months. ____ Years. 4. Did your symptoms start? 5. Are your symptoms? ____Comes and goes. 6. When do you have the least symptoms? ___Morning. ___Afternoon. ___ Evening. ___Night. 7. When do you have the most symptoms? ___Morning. ___Afternoon. ___ Evening. ___Night. Rest. Activity. Medication. Exercises. Heat. Ice. Others__________________________ Rest. Activity. Medication. Exercises. Heat. Ice. Others__________________________ 10. Do your symptoms disturb your sleep? ___Yes. __ No. 11. Do you get enough sleep at night? ___Yes. __ No. 12. Do you wake up feeling rested? ___Yes. __ No. 13. Did you have any of the following prior to the onset of your symptoms? Viral syndrome. Stomach virus. Stressful situation. Car accident. Other injury. Others:_______________________________________________________________ 14. Do you have joint swelling? ___No ___Yes 15. Do you have morning stiffness? ___No ___Yes How long does the morning stiffness last? Minutes: 5. 10. 15. 30. 45. 16. Do you have muscle weakness? ___No ___Yes Name: _____________________________________
: Are you allergic to any medication? ___NO. ___Yes,
If yes, to what?
___Penicillin, what happened?_______________________________________________ ___Sulfa, what happened?__________________________________________________ ___Aspirin, what happened?_________________________________________________ ___Others, what happened?_________________________________________________ Please check an Arthritis Medications you have used in the PAST:
Do you now have, or have you ever had (check if Yes):
Other significant illness:________________________________________________________________ Previous Operations:___________________________________________________________________ Any previous fractures? ___No. ___Yes:__________________________________________________ Date of last Bone Densitometry (DEXA):___________________________________________________ SOCIAL HISTORY:
Marital Status: ___Never Married ___Married ___Separated ___Divorced ___Widowed
Employment: ___F/T ___P/T ___Student ___Homemaker ___Disabled ___Unemployed
Do you smoke?
Do you drink Alcohol?
Do you exercise regularly? ___No.

Do you know of any blood relative that currently has or has previously had:
___Arthritis (Unknown Type)
___Other significant illness:___________________________________________________________________ Name: _____________________________________

Please describe briefly your symptoms. (In other words, what brings you to us today?)
Please check any items that have significantly affected you.
For Women Only:

Please list any medications you are taking, INCLUDING over the counter items such as aspirin, vitamins,
laxatives, calcium, herbal supplements, etc. Please include dosage and frequency.


In the name of allah, the most beneficent, the most merciful

Imams & Mosques Council (UK), The Muslim Law (Shariah) Council UK, Utrujj Foundation, Muslim Council of Britain, The Muslim Parliament of Great Britain, The City Circle, Muslim Women’s Network-UK, Fatima Network, Muslim Community Helpline (Ex-MWH) Introduction: a Guide to a Happy Marriage In the Shari‘ah, marriage ( nikah ) is a relationship of mutual love,

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