REGISTRATION FORM
PATIENT’S NAME SOC. SEC. NO..
DATE OF BIRTH AGE SEX M_ F_ MARRIED__ SINGLE__
PATIENT'S ADDRESS CITY ZIP
TELEPHONE: HOME WK CELL EMAIL
EMPLOYER OCCUPATION
EMERGENCY CONTACT: NAME PHONE CELL
PRIMARY INSURANCE
SECONDARY INSURANCE
PRIMARY PHYSICIAN: NAME TELEPHONE
ADDRESS CITY ZIP_
Whom, may we thank for referring you _ NAME PHONE
If someone other than the patient is responsible for payment please complete this section:
Name of responsible party Relationship Soc.Sec.
Employed by Telephone
I, The Undersigned, have insurance coverage with _________________and
assign directly to Arthritis Care Center all medical benefits, if any, otherwise payable to me for services rendered. I
understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor
to release all information necessary to secure the payment of benefits
SIGNED. DATE
PATIENT’S NAME SOC. SEC. NO..
DATE OF BIRTH AGE SEX M_ F_ MARRIED__ SINGLE__
PATIENT'S ADDRESS CITY ZIP
TELEPHONE: HOME WK CELL EMAIL
EMPLOYER OCCUPATION
EMERGENCY CONTACT: NAME PHONE CELL
PRIMARY INSURANCE
SECONDARY INSURANCE
PRIMARY PHYSICIAN: NAME TELEPHONE
ADDRESS CITY ZIP_
Whom, may we thank for referring you _ NAME PHONE
If someone other than the patient is responsible for payment please complete this section:
Name of responsible party Relationship Soc.Sec.
Employed by Telephone
I, The Undersigned, have insurance coverage with _________________and
assign directly to Arthritis Care Center all medical benefits, if any, otherwise payable to me for services rendered. I
understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor
to release all information necessary to secure the payment of benefits
SIGNED. DATE
Arthritis Care Center; Inc.
M E D I C AL HISTORY FORM
DATE
PATIENT’S NAME AGE DATE OF BIRTH
EXPLAIN BRIEFLY WHAT SYMPTOMS BRING YOU TO THIS OFFICE:
ARE ANY OF YOUR PRESENT PROBLEMS DUE TO INJURY? Yes , No___Industrial?^
ARE YOU RIGHT-HANDED [ ] OR LEFT-HANDED [ ]?
PAST MEDICAL HISTORY:
HAVE YOU EVER HAD: (Check the appropriate boxes and list year to the right)
[ ] Measles
[ ] German Measles
[ ] Chickenpox
[ ] Mumps
[ ] Diphtheria
[ ] Rheumatic Fever
[ ] Polio
[ ] Meningitis
[ ] Tuberculosis (or positive test)
[ ] Valley Fever (or positive test)
[ ] Malaria
[ ] Parasites
[ ] Syphilis (or positive test)
[ ] Gonorrhea
[ ] AIDS, ARC (or positive test)
[ ] Genital Herpes
[ ] Lyme Disease
[ ] High blood pressu
[ ] Angina Pectoris
[ ] Heart Attack
[ ] Stroke
[ ] Pericarditis
[ ] Heart Murmurs
[ ] High Cholesterol
[ ] High Triglycerides
[ ] Cancer
[ ] Nephritis
[ ] Kidney Stones
[ ] Diabetes
[ ] Thyroid Disease
[ ] Gout
[ ] High Uric Acid
[ ] Gastric Ulcer
[ ] Duodenal Ulcer
[ ] Bleeding Ulcer
[ ] Anemia
[ ] Pancreatitis
[ ] Ulcerative Colitis
[ ] Crohn's Disease
[ ] Sarcoidosis
[ ] Osteoporosis
[ ] Paget's Disease
[ ] Hepatitis
[ ] Cirrhosis
[ ] Gallbladder Problems
[ ] Epilepsy
[ ] Pneumonia
[ ] Pleurisy
[ ] Asthma
[ ] Hay Fever
[ ] Chronic Bronchitis
[ ] Emphysema
[ ] Psychiatric Illness
[ ] Alcoholism
[ ] Drug Addiction
PLEASE LIST IN CHRONOLOGICAL ORDER ALL HOSPITALIZATIONS, SERIOUS
ILLNESSES, OPERATIONS, SEVERE INJURIES, AND BROKEN BONES.
LIST CONDITION OR OPERATION, DATE, HOSPITAL CITY STATE DOCTOR
-Attach a separate page for this if needed.
PLEASE LIST MEDICATIONS THAT YOU ARE CURRENTLY TAKING: Attach a separate page for this if needed.
Please bring your medications with you to your office visit.
MEDICATION DOSE FREQUENCY,
HAVE YOU EVER TAKEN?: (Please check the appropriate boxes)
[ ] Injected Biological Drugs for Arthritis or related diseases
[ ] ACTH (injection)
[ ] Allopurinol (zyloprim)
[ ] Anturane. (sulfinpyrazone)
[ ] Azulfidine (sulfasalazine)
[ ] Benemid (probenecid)
[ ] Clinoril (sulindac)
[ ] Colchicine or Colbenemid
[ ] Cortisone - By Mouth___, By Injection___
[ ] Cytoxan (cyclophosphamide)
[ ] Feldene (piroxicam)
[ ] Gold – Ridaura, By Mouth , ___ or Myochrysine or Solganol, By Injection,___
[ ] Imuran (azathioprine)
[ ] Indocin (indomethacin
[ ] Lodine (etodolac)
[ ] Motrin (ibuprofen)
[ ] Meclomen (meclophenamate)
[ ] Naprosyn (naproxen)
[ ] Penicillamine (cuprimine)
[ ] Plaquenil (hydroxychloroquine)
[ ] Rheumatrex (methotrexate)
[ ] Tolectin (tolmetin).
[ ] Other Arthritis Medications?
PLEASE LIST ALL MEDICATIONS THAT YOU do not tolerate or are allergic to:
LIST MEDICATION, TYPE OF REACTION,
PLEASE LIST ALLERGIES OTHER THAN DRUG RELATED:,
HAVE YOU RECENTLY RECEIVED PHYSICAL THERAPY?
[ ] Hot packs [ ] Exercises [ ] Splints
[ ] Cold packs [ ] Massage [ ] Canes, Braces
[ ] Paraffin [ ] Traction [ ] Crutches
[ ] Whirlpool [ ] Electrotherapy [ ] Cervical Collar or Cervical Pillow
WHEN WERE YOU LAST IMMUNIZED AGAINST:
[ ] German Measles [ ] Tetanus [ ] Influenza [ ] Pneumococcus [ ] Hepatitis B
MARITAL HISTORY:
Your present status:.
How Long?_
Spouse: Occupation & health.
Are you satisfied with your present marital status?_
SOCIAL HISTORY:
Work: Hours per week_ Occupation^
Have you missed work due to this illness or injury? Yes_ No __. If Yes, please explain
Date last worked:
Date returned to part-time work:_
Date returned to full-time work:
Birthplace: . Your Ethnic Origin
How long have you been in Santa Clara County?.
With whom do you live? .
Do you exercise regularly?____Do you follow a special diet?____
How much tobacco per day?______Alcohol: Daily__, Occasionally__, Rarely___ Never___.
FAMILY HISTORY: (Please list each member separately)
RELATIVE. AGE, HEALTH if living, or …
IF DECEASED, CAUSE OF DEATH and AGE AT DEATH
FATHER
MOTHER
BROTHERS
SISTERS
DAUGHTERS
SONS
HAS ANY BLOOD RELATIVE HAD: (Please list who)
[ ] Rheumatoid Arthritis
[ ] Spondylitis (spine inflammation)
[ ] Osteoarthritis (degenerative arthritis)
[ ] Lupus Erythematosus
[ ] Polyarteritis, [ ] Dermatomyositis, [ ] Polymyositis
[ ] Scleroderma, [ ] Raynaud's Disease
[ ] Psoriasis
[ ] Osteoporosis, [ ] Hip or Spine Fractures
[ ] Gout
ARE YOU NOW TROUBLED WITH:
MUSCULOS KELETAL SYMPTOMS?:
[ ] Swollen Joints - where?_
[ ] Painful Joints - where?_
[ ] Morning Stiffness - where?. How Long (Hours before improvement)?
[ ] Neck Pain
[ ] Upper Back Pain
[ ] Lower Back Pain
[ ] Heel Pain
[ ] Muscle Pain
[ ] Muscle Weakness
SKIN:
[ ] Rash
[ ] Psoriasis
[ ] Lumps or Nodules
[ ] Skin Sensitivity to Sunlight
[ ] Change in Skin Texture, Color, or Moisture
[ ] Easy Bruising or Bleeding
[ ] Skin Ulcers
[ ] Abnormal Hair Loss
[ ] Fingers Turning While on Exposure to Cold
GASTROINTESTINAL SYMPTOMS?:
[ ] Heartburn
[ ] Nausea
[ ] Vomiting
[ ] Vomiting Blood
[ ] Abdominal Pain
[ ] Constipation
[ ] Diarrhea
[ ] Yellow Jaundice
[ ] Recent Change in Bowel Habits
[ ] Stools Which Are ( )Black; ( )Bloody
GENERAL SYMPTOMS
[ ] Dizziness
[ ] Fever
[ ] Shaking Chills
[ ] Excessive or Unusual Fatigue
[ ] Recurrent Infections
[ ] Swollen Glands
[ ] Glaucoma (increased eye pressure)
[ ] Kidney Stones
[ ] Diabetes
[ ] TB
[ ] Cancer
[ ] Birth Defects
[ ] Stroke
[ ] Blood Disorders
[ ] Alcoholism, [ ] Drug Addiction
EYES:
[ ] Impaired or Changing Vision
[ ] Double Vision
[ ] Persistent Dry Eyes
[ ] Eye Inflammation
[ ] Glaucoma
[ ] Cataracts
[ ] Glasses
[ ] Do you use artificial tears?
EARS:
[ ] Deafness
[ ] Ringing in Ears
[ ] Hearing Aid
NOSE:
[ ]Sinus Trouble - Type_
[ ]Nose Bleeds
MOUTH, THROAT:
[ ] Mouth Ulcers
[ ] Persistent Dry Mouth
[ ] Hoarseness
[ ] Sore Throats
[ ] Jaw Pain With Chewing
[ ] Difficulty Swallowing
CARDIOVASCULAR, and RESPIRATORY
[ ] Shortness of Breath
[ ] Chest Pain
[ ] Cough
[ ] Coughing Up Blood
[ ] Leg Swelling
[ ] Palpitations
GENITOURINARY:
[ ] Urinary Tract Infections
[ ] Frequency of Urination ( )Times per day, ( )Times per night
[ ] Burning with Urination
[ ] Blood in Urine
[ ] Urgency of Urination
[ ] Discharge From the Penis
[ ] Excessive Vaginal Discharge
[ ] Difficulty Starting ___ or Stopping___ Flow of Urine
[ ] Rash or Sores on Genitals
MENSTRUAL HISTORY:Age at First menses____, last menses___. Post menopausal?___
Age at Onset of Menstruation____Duration of Flow (days)___, Days Between Periods____
Symptoms with Periods?.
First Day of Last Period.___________Number of Pregnancies___ Number of Children___
METABOLIC:
[] Unusual Heat Intolerance
[ ] Unusual Cold Intolerance
[ ] Excessive Thirst
[ ] Excessive Urination
[ ] Excessive Appetite
[ ] Loss of Appetite
[ ] Weight Loss Gain Since When?_
[ 1 Hot Flashes
NEUROLOGIC:
[ ] Headaches: ( )Migraine, ( )Sinus, ( )Tension
[ ] Numbness, Burning, or Tingling - Where?
[ ] Loss of Memory
[ ] Loss of Consciousness
[ ] Nervousness
[ ] Depression
[ ] Suicidal Ideas
[ ] Difficulty Sleeping
[ ] Any Other Medical Problems or Symptoms?
Please bring with you the names and addresses where pertinent medical records, laboratory
tests, and x-rays might be obtained. We can then request what records we need.
Thank You.
M E D I C AL HISTORY FORM
DATE
PATIENT’S NAME AGE DATE OF BIRTH
EXPLAIN BRIEFLY WHAT SYMPTOMS BRING YOU TO THIS OFFICE:
ARE ANY OF YOUR PRESENT PROBLEMS DUE TO INJURY? Yes , No___Industrial?^
ARE YOU RIGHT-HANDED [ ] OR LEFT-HANDED [ ]?
PAST MEDICAL HISTORY:
HAVE YOU EVER HAD: (Check the appropriate boxes and list year to the right)
[ ] Measles
[ ] German Measles
[ ] Chickenpox
[ ] Mumps
[ ] Diphtheria
[ ] Rheumatic Fever
[ ] Polio
[ ] Meningitis
[ ] Tuberculosis (or positive test)
[ ] Valley Fever (or positive test)
[ ] Malaria
[ ] Parasites
[ ] Syphilis (or positive test)
[ ] Gonorrhea
[ ] AIDS, ARC (or positive test)
[ ] Genital Herpes
[ ] Lyme Disease
[ ] High blood pressu
[ ] Angina Pectoris
[ ] Heart Attack
[ ] Stroke
[ ] Pericarditis
[ ] Heart Murmurs
[ ] High Cholesterol
[ ] High Triglycerides
[ ] Cancer
[ ] Nephritis
[ ] Kidney Stones
[ ] Diabetes
[ ] Thyroid Disease
[ ] Gout
[ ] High Uric Acid
[ ] Gastric Ulcer
[ ] Duodenal Ulcer
[ ] Bleeding Ulcer
[ ] Anemia
[ ] Pancreatitis
[ ] Ulcerative Colitis
[ ] Crohn's Disease
[ ] Sarcoidosis
[ ] Osteoporosis
[ ] Paget's Disease
[ ] Hepatitis
[ ] Cirrhosis
[ ] Gallbladder Problems
[ ] Epilepsy
[ ] Pneumonia
[ ] Pleurisy
[ ] Asthma
[ ] Hay Fever
[ ] Chronic Bronchitis
[ ] Emphysema
[ ] Psychiatric Illness
[ ] Alcoholism
[ ] Drug Addiction
PLEASE LIST IN CHRONOLOGICAL ORDER ALL HOSPITALIZATIONS, SERIOUS
ILLNESSES, OPERATIONS, SEVERE INJURIES, AND BROKEN BONES.
LIST CONDITION OR OPERATION, DATE, HOSPITAL CITY STATE DOCTOR
-Attach a separate page for this if needed.
PLEASE LIST MEDICATIONS THAT YOU ARE CURRENTLY TAKING: Attach a separate page for this if needed.
Please bring your medications with you to your office visit.
MEDICATION DOSE FREQUENCY,
HAVE YOU EVER TAKEN?: (Please check the appropriate boxes)
[ ] Injected Biological Drugs for Arthritis or related diseases
[ ] ACTH (injection)
[ ] Allopurinol (zyloprim)
[ ] Anturane. (sulfinpyrazone)
[ ] Azulfidine (sulfasalazine)
[ ] Benemid (probenecid)
[ ] Clinoril (sulindac)
[ ] Colchicine or Colbenemid
[ ] Cortisone - By Mouth___, By Injection___
[ ] Cytoxan (cyclophosphamide)
[ ] Feldene (piroxicam)
[ ] Gold – Ridaura, By Mouth , ___ or Myochrysine or Solganol, By Injection,___
[ ] Imuran (azathioprine)
[ ] Indocin (indomethacin
[ ] Lodine (etodolac)
[ ] Motrin (ibuprofen)
[ ] Meclomen (meclophenamate)
[ ] Naprosyn (naproxen)
[ ] Penicillamine (cuprimine)
[ ] Plaquenil (hydroxychloroquine)
[ ] Rheumatrex (methotrexate)
[ ] Tolectin (tolmetin).
[ ] Other Arthritis Medications?
PLEASE LIST ALL MEDICATIONS THAT YOU do not tolerate or are allergic to:
LIST MEDICATION, TYPE OF REACTION,
PLEASE LIST ALLERGIES OTHER THAN DRUG RELATED:,
HAVE YOU RECENTLY RECEIVED PHYSICAL THERAPY?
[ ] Hot packs [ ] Exercises [ ] Splints
[ ] Cold packs [ ] Massage [ ] Canes, Braces
[ ] Paraffin [ ] Traction [ ] Crutches
[ ] Whirlpool [ ] Electrotherapy [ ] Cervical Collar or Cervical Pillow
WHEN WERE YOU LAST IMMUNIZED AGAINST:
[ ] German Measles [ ] Tetanus [ ] Influenza [ ] Pneumococcus [ ] Hepatitis B
MARITAL HISTORY:
Your present status:.
How Long?_
Spouse: Occupation & health.
Are you satisfied with your present marital status?_
SOCIAL HISTORY:
Work: Hours per week_ Occupation^
Have you missed work due to this illness or injury? Yes_ No __. If Yes, please explain
Date last worked:
Date returned to part-time work:_
Date returned to full-time work:
Birthplace: . Your Ethnic Origin
How long have you been in Santa Clara County?.
With whom do you live? .
Do you exercise regularly?____Do you follow a special diet?____
How much tobacco per day?______Alcohol: Daily__, Occasionally__, Rarely___ Never___.
FAMILY HISTORY: (Please list each member separately)
RELATIVE. AGE, HEALTH if living, or …
IF DECEASED, CAUSE OF DEATH and AGE AT DEATH
FATHER
MOTHER
BROTHERS
SISTERS
DAUGHTERS
SONS
HAS ANY BLOOD RELATIVE HAD: (Please list who)
[ ] Rheumatoid Arthritis
[ ] Spondylitis (spine inflammation)
[ ] Osteoarthritis (degenerative arthritis)
[ ] Lupus Erythematosus
[ ] Polyarteritis, [ ] Dermatomyositis, [ ] Polymyositis
[ ] Scleroderma, [ ] Raynaud's Disease
[ ] Psoriasis
[ ] Osteoporosis, [ ] Hip or Spine Fractures
[ ] Gout
ARE YOU NOW TROUBLED WITH:
MUSCULOS KELETAL SYMPTOMS?:
[ ] Swollen Joints - where?_
[ ] Painful Joints - where?_
[ ] Morning Stiffness - where?. How Long (Hours before improvement)?
[ ] Neck Pain
[ ] Upper Back Pain
[ ] Lower Back Pain
[ ] Heel Pain
[ ] Muscle Pain
[ ] Muscle Weakness
SKIN:
[ ] Rash
[ ] Psoriasis
[ ] Lumps or Nodules
[ ] Skin Sensitivity to Sunlight
[ ] Change in Skin Texture, Color, or Moisture
[ ] Easy Bruising or Bleeding
[ ] Skin Ulcers
[ ] Abnormal Hair Loss
[ ] Fingers Turning While on Exposure to Cold
GASTROINTESTINAL SYMPTOMS?:
[ ] Heartburn
[ ] Nausea
[ ] Vomiting
[ ] Vomiting Blood
[ ] Abdominal Pain
[ ] Constipation
[ ] Diarrhea
[ ] Yellow Jaundice
[ ] Recent Change in Bowel Habits
[ ] Stools Which Are ( )Black; ( )Bloody
GENERAL SYMPTOMS
[ ] Dizziness
[ ] Fever
[ ] Shaking Chills
[ ] Excessive or Unusual Fatigue
[ ] Recurrent Infections
[ ] Swollen Glands
[ ] Glaucoma (increased eye pressure)
[ ] Kidney Stones
[ ] Diabetes
[ ] TB
[ ] Cancer
[ ] Birth Defects
[ ] Stroke
[ ] Blood Disorders
[ ] Alcoholism, [ ] Drug Addiction
EYES:
[ ] Impaired or Changing Vision
[ ] Double Vision
[ ] Persistent Dry Eyes
[ ] Eye Inflammation
[ ] Glaucoma
[ ] Cataracts
[ ] Glasses
[ ] Do you use artificial tears?
EARS:
[ ] Deafness
[ ] Ringing in Ears
[ ] Hearing Aid
NOSE:
[ ]Sinus Trouble - Type_
[ ]Nose Bleeds
MOUTH, THROAT:
[ ] Mouth Ulcers
[ ] Persistent Dry Mouth
[ ] Hoarseness
[ ] Sore Throats
[ ] Jaw Pain With Chewing
[ ] Difficulty Swallowing
CARDIOVASCULAR, and RESPIRATORY
[ ] Shortness of Breath
[ ] Chest Pain
[ ] Cough
[ ] Coughing Up Blood
[ ] Leg Swelling
[ ] Palpitations
GENITOURINARY:
[ ] Urinary Tract Infections
[ ] Frequency of Urination ( )Times per day, ( )Times per night
[ ] Burning with Urination
[ ] Blood in Urine
[ ] Urgency of Urination
[ ] Discharge From the Penis
[ ] Excessive Vaginal Discharge
[ ] Difficulty Starting ___ or Stopping___ Flow of Urine
[ ] Rash or Sores on Genitals
MENSTRUAL HISTORY:Age at First menses____, last menses___. Post menopausal?___
Age at Onset of Menstruation____Duration of Flow (days)___, Days Between Periods____
Symptoms with Periods?.
First Day of Last Period.___________Number of Pregnancies___ Number of Children___
METABOLIC:
[] Unusual Heat Intolerance
[ ] Unusual Cold Intolerance
[ ] Excessive Thirst
[ ] Excessive Urination
[ ] Excessive Appetite
[ ] Loss of Appetite
[ ] Weight Loss Gain Since When?_
[ 1 Hot Flashes
NEUROLOGIC:
[ ] Headaches: ( )Migraine, ( )Sinus, ( )Tension
[ ] Numbness, Burning, or Tingling - Where?
[ ] Loss of Memory
[ ] Loss of Consciousness
[ ] Nervousness
[ ] Depression
[ ] Suicidal Ideas
[ ] Difficulty Sleeping
[ ] Any Other Medical Problems or Symptoms?
Please bring with you the names and addresses where pertinent medical records, laboratory
tests, and x-rays might be obtained. We can then request what records we need.
Thank You.
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