Premier Rheumatology and Endocrinology Adam S. Barron, M.D. • Renanit E. Barron, M.D.

5155 Corporate Way • Suite C • Jupiter, FL 33458 5730 Corporate Way • Suite 200 • West Palm Beach, FL 33407

Tel: 561-881-3022 Fax: 561-881-3088

PATIENT INFORMATION

Please print and complete as accurately as possible Name: ________________________________________________________________________ Last First Middle Mailing Address: ______________________________________________________ City: _________________________ State: ________ Zip:_________ Home Phone: ( ) __________ Cell Phone: ( ) __________ Other Address (if applicable): _____________________________________________ City: _________________________ State:________ Zip:_________ Phone ( ) __________ Social Security Number: _______-_______-_______ Date of Birth: _____/_____/______ Age: ______ Month Day Year How did you hear about us? _________________________________________________________ YOUR EMPLOYER INFORMATION (if applicable) Name of Employer: _________________________________ Phone: ( ) _______________ Address: __________________________ City___________________ State______ Zip Code_______ SPOUSE EMPLOYER INFORMATION (if applicable) Name of Employer: _________________________________ Phone: ( ) _______________ Address: __________________________ City___________________ State______ Zip Code_______

Your relation to policy holder: □ Self □ Spouse □ Dependent Child Social Security Number of Policyholder___________________ Date of Birth of Policyholder_______________________

INSURANCE INFORMATION Insurance Company: ________________________________________________________________ Address: ___________________________________________________________________________ City: ________________________ State: ________ Zip: ___________ Phone: ( ) _______________ Policyholder Name: ____________________________________________________________________

RHEUMATOLOGY QUESTIONNAIRE Adam S. Barron, M.D.

Patient Name _____________________________

1

Date of Birth: _________________ Age: _______________

Date of Appointment: ______________________________

Name of person referring you here: ________________________________________________________

Reason for your visit to Rheumatology office: ________________________________________________

When did you first notice this problem (month/year?): __________________________________________

List other practitioners you have seen for this problem: _________________________________________

MEDICATION

Name of Medication Dose # at a time

#times per day

Name of Medication Dose # at a time

# times per day

1 7

2 8

3 9

4 10

5 11

6 12

List any medicines you are allergic to: ______________________________________________________

List any vitamins, supplements or herbs: _____________________________________________________

PAST MEDICAL HISTORY: Please check if you have had any of the following conditions:

HEAD/EARS/EYES/THROAT

Cataract

Glaucoma

Migraine Headaches

Sinus Infections

HEART

Rheumatic Fever

Heart Attack/Myocardial

Infarction

Heart Murmur

Angina

Heart Failure

Heart Palpitation

High Blood Pressure

LUNGS

Tuberculosis/TB Exposure/

+ TB Skin Test

Emphysema

Pneumonia

Pleurisy

Blood Clot in Lung

Asthma

GASTROINTESTINAL

Stomach/Duodenal Ulcer

Cirrhosis

Hepatitis

Gallstones

Pancreatic Disease

Intestinal Polyp

GASTROINTESTINAL cont.

Esophageal Disease/Reflux

Colitis

Diverticulitis

Crohn’s

Irritable Bowel Syndrome

NEUROLOGIC/PSYCHIATRIC

Meningitis

Stroke/Paralysis

Seizures/Epilepsy

Depression

Nervous Breakdown

RHEUMATOLOGY QUESTIONNAIRE Adam S. Barron, M.D.

Patient Name _____________________________

2

ENDOCRINE

Thyroid Disease

Diabetes

Goiter

SKIN

Skin Ulcers – Lower Leg

Fingers Turning

White/Raynaud’s

Psoriasis

Other Rashes

Other Skin Conditions:

_____________________

GENITOURINARY

Nephritis/Kidney Disease

Kidney Infection

Kidney Stones

Syphilis

Gonorrhea

Chlamydia

Genital Herpes

MUSCULOSKELETAL

Rheumatoid Arthritis

Gout

Lupus

Serious Joint Injury (ies)

Broken Bones

Disabling Back Pain

Degenerative Arthritis

Osteoporosis

HEMATOLOGY/ONCOLOGY

Anemia

Blood transfusions

Blood Clots in Leg

Bleeding Tendency

Cancer

Type: _________________

Tattoos

OTHER

Alcoholism

Drug Abuse

HIV Testing Yes No

Result: ____________

Other (explain)_________

________________________

AIDS

WOMEN ONLY

Pregnancy(ies) & Number

Miscarriage(s) & Number

Toxemia/Eclampsia

OTHER SIGNIFICANT ILLNESS(ES) List:__________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Please list all of your previous hospitalizations and surgeries below:

CONDITION OR PROCEDURE YEAR CONDITION OR PROCEDURE YEAR

1 6

2 7

3 8

4 9

5 10

RHEUMATOLOGY QUESTIONNAIRE Adam S. Barron, M.D.

Patient Name _____________________________

3

Any previous fractures? Yes No

If yes, describe _________________________________________________________________________

SYSTEMS REVIEW Date of last mammogram: _______________________ Date of last pap: ______________________

As you review the following list, please check any of those problems which have significantly affected

you in the past six months.

CONSTITUTIONAL

Recent weight gain amount:

_______________________

Recent weight loss amount:

_______________________

Fatigue

Weakness

Fever

EYES

Pain

Redness

Loss of vision

Double or blurred vision

Dryness

Feels like something in eye

Itching eyes

EARS-NOSE-MOUTH-THROAT

Ringing in ears

Loss of hearing

Nosebleeds

Loss of smell

Dryness in nose

Runny nose

Sore tongue

Bleeding gums

EARS-NOSE-MOUTH-

THROAT (cont.)

Sores in mouth

Loss of taste

Dryness of mouth

Frequent sore throats

Hoarseness

Difficulty in swallowing

Recent dental work

GASTROINTESTINAL

Nausea

Vomiting of blood or coffee

ground material

Stomach pain relieved by food

or milk

Jaundice/yellow skin

Increasing constipation

Persistent diarrhea

Blood in stools

Black stools

Heartburn

GENITOURINARY

Difficult urination

Pain or burning on urination

Blood urine

Cloudy “smoky” urine

Pus in urine

Discharge from penis/vagina

Getting up at night to pass urine

Vaginal dryness

Genital rash/ulcers/sores

CARDIOVASCULAR

Pain in chest

Irregular heart beat

Sudden changes in heart beat

High blood pressure

Heart murmurs

RESPIRATORY

Shortness of breath

Difficulty in breathing at night

Swollen legs or feet

Cough

Coughing of blood

Wheezing (asthma)

Loud snoring

Not rested after sleeping

INTEGUMENTARY (skin and

or breast)

Skin thickening

Easy bruising

Redness

Rash

RHEUMATOLOGY QUESTIONNAIRE Adam S. Barron, M.D.

Patient Name _____________________________

4

INTEGUMENTARY (skin and or

breast) (cont.)

Hives

Sun sensitive (sun allergy) / rash

in the sun

Tightness

Nodules/bumps on the skin

Hair loss

Color changes of hands or feet in

the cold

Breast lump

MUSCULOSKELETAL

Morning stiffness

Lasting how long?

______minutes _______hours

Joint pain

Joint swelling

List joints affected in last 6

months:

_____________________________

Muscle weakness

Muscle tenderness

Shoulder pain/stiffness

Hip pain, stiffness

Jaw pain with chewing

Low back pain/stiffness mainly

in the morning

ENDOCRINE

Excessive thirst

PSYCHIATRIC

Excessive worries

Anxiety

Easily losing temper

Depression

Agitation

Difficulty falling asleep

Difficulty staying asleep

NEUROLOGICAL

Headaches

Scalp tenderness

Numbness/tingling

Dizziness

Fainting

Muscle pain

Muscle spasm

Loss of consciousness

Sensitivity or pain of hands

and/or feet

Memory loss

Night sweats

Decreased concentration

HEMATOLOGIC/LYMPHATIC

Swollen glands

Tender glands

Anemia

Bleeding tendency

Transfusion/when _________

ALLERGIC/IMMUNOLOGIC

Frequent sneezing

Increased susceptibility to

infection

RHEUMATOLOGY QUESTIONNAIRE Adam S. Barron, M.D.

Patient Name _____________________________

5

PAIN ASSESSMENT: How much pain have you had in the PAST WEEK? Place a mark on the line: NO___________________________________________________________________PAIN AS BAD AS PAIN IT COULD BE SOCIAL HISTORY Your Occupation: ___________________________

Level of Education: _________________________

Are you currently working? Yes No

Do you receive disability or SSI? Yes No

Marital status: Single Married Separated

Divorced Widowed Partnered

How many drinks/glasses of alcohol do you have

per week? _________________________________

Do you smoke cigarettes? Yes No

If you quit, how may years did you smoke? _____

Have you ever used recreational drugs?

Yes No If yes, list type

____________________________________

RHEUMATOLOGIC (ARTHRITIS HISTORY): At any time have you or a blood relative had any of the following? Check if “yes” Relative Name / Relationship

Yourself Relative Name / Relationship

Yourself

Arthritis (unknown) Lupus or “SLE”

Osteoarthritis Rheumatoid Arthritis

Gout Ankylosing Spondylitis

Childhood arthritis Osteoporosis

Fibromyalgia Psoriatic arthritis

Muscle disease

FAMILY HISTORY

IF LIVING

Age

IF DECEASED

Any medical conditions: Age died Cause

Father

Mother

How may

living? Any medical conditions: Any who

died? List ages each died and cause below:

Brothers

Sisters

Children

RHEUMATOLOGY QUESTIONNAIRE Adam S. Barron, M.D.

Patient Name _____________________________

6

Please list all physicians you are currently seeing: Place a check mark next to the physicians’ names, to which you would like a copy of the visit notes sent.

1)

Physician Name

Address

Specialty Phone Number

2)

FAX Number

Physician Name

Address

Specialty Phone Number

3)

FAX Number

Physician Name

Address

Specialty Phone Number

4)

FAX Number

Physician Name

Address

Specialty Phone Number

5)

FAX Number

Physician Name

Address

Specialty Phone Number

6)

FAX Number

Physician Name

Address

Specialty Phone Number

Patient’s Signature _______________________________________________________________

FAX Number