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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: _____________________________________
ALLERGIES
: 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:
PAST MEDICAL HISTORY:
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
Occupation:___________________________________________
Do you smoke?
Do you drink Alcohol?
Do you exercise regularly? ___No.

FAMILY HISTORY:
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?)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
REVIEW OF SYMPTOMS:
Please check any items that have significantly affected you.
Skin:
Endocrine:
Hematologic:
Psychiatric:
Respiratory:
Gastrointestinal:
For Women Only:
Mouth/Throat:
Genitourinary:

PRESENT MEDICATIONS:
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.
1

Source: http://www.m-o-i.com/pdf/moi/Rheumatology_Patient_Form_%20Alghafeer.pdf

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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