Supriya Sehgal, M.D.

Rheumatology

2821 E. George Bush Hwy., Suite 305

Richardson, Texas, 75082

Tel: 972-235-3248 Fax: 972-235-3984

Patient History Form:

What is the reason for your visit today?

______

Please list all your current and past medical illnesses:

______

Please list any surgeries that you have had in the past, and the reason for the surgery:

______

Please list your family history of diseases, and which family member had that illness (e.g., mother, father, sibling, child):

______

Medication list:

Medication Name / Dose / Route taken / How many times do you take it per day?

Please list all of your drug allergies and adverse reactions:

Name of Drug / Reaction to Drug

Social History:

Do you smoke (circle one)? Y/N

If you do smoke:

1. How many packs per day?______

2. For how many years have you been smoking?______

Do you drink any alcohol (circle one)? Y/N

If you do drink alcohol:

1. How many drinks per week?______

2. Of what alcoholic beverage?______

Do you have any history of blood transfusions? Y/N

Do you have any tattoos? Y/N

Do you have any history of illicit/injectable drug use (circle one)? Y/N

If you have used illicit/injectable drugs in the past, please list the drug used and if you are still using this drug or have quit.

______

Do you have any history of any drug addictions/abuse? Y/N

If you do have a history of addictions, please list the drugs used and the duration of use.

______

Reproductive history for women:

Number of pregnancies______

Number of live births______

Number of still births______

Number of abortions______

Number of miscarriages______

Are you sexually active at this time?Y/N

How many partners have you had in the last year?______

Are you currently using contraception? Y/N

If you are using contraception, what form(s) are you using? ______

Have you ever been diagnosed with any sexually transmitted diseases? Y/N

If you have been diagnosed with sexually transmitted diseases in the past, please list the name of the disease, when you were diagnosed and how you were treated:

______

Reproductive history for men:

Are you sexually active at this time? Y/N

Are you currently using contraception? Y/N

If you are using contraception, what form(s) are you using? Y/N

How many partners have you had in the last year?______

Have you ever been diagnosed with any sexually transmitted diseases? Y/N

Review of Systems: Please Circle yes or no to each Question:

General: / Eye:
Chills? Y/N / Eye pain? Y/N
Fatigue? Y/N / Dry eyes? Y/N
Fever? Y/N / Does the light bother your eyes excessively? Y/N
Weight Loss? Y/N / Red eyes? Y/N
Weight Gain? Y/N / sudden loss of vision in one or both eyes? Y/N
Night Sweats? Y/N / abnormal eye discharge? Y/N
Sleep Disturbance? Y/N / Head, Ears, Nose, Throat:
Cardiovascular: / Sudden hearing loss? Y/N
Chest pain? Y/N / Feeling that the room is spinning? Y/N
Chest tightness? Y/N / Ear pain or redness? Y/N
Shortness of breath on exertion? Y/N / Jaw or tongue pain with chewing? Y/N
Shortness of breath at rest? Y/N / Dry mouth? Y/N
Hands turn blue, then white, then red in the cold? Y/N / Ulcers in the mouth? Y/N
Leg or foot pain with exertion? Y/N / Swelling of the side of your face? Y/N
Hand or arm pain with exertion? Y/N / Hoarseness of voice? Y/N
Leg swelling? Y/N / Sinusitis symptoms? Y/N
Palpitations? Y/N / Excessive nosebleeds? Y/N
Loss of consciousness? Y/N / Any ulcers or perforations in your nose? Y/N
Endocrine: / Hematologic:
Excessive thirst or urination? Y/N / Palpable masses in your neck/armpits/groin area? Y/N
Excessive heat or cold intolerance? Y/N / Excessively easy bruising or bleeding? Y/N
Excessively moist or dry skin? Y/N / History of blood clots? Y/N
Goiter? Y/N

Review of Systems Continued:

Gastrointestinal: / Respiratory:
Loss of appetite? Y/N / Cough?
Feelings of excessive fullness after eating? Y/N / Shortness of breath at rest?
Difficulty swallowing? Y/N / Blood in your sputum?
Excessive constipation or diarrhea? Y/N / Recurrent pneumonia?
Heartburn? Y/N / Skin:
Jaundice? Y/N / Hair loss? Y/N
Nausea? Y/N / Areas of excessively tight skin? Y/N
Vomiting? Y/N / Rashes? Y/N
Blood in your stool or black tarry stool? Y/N / Rash or feeling of unwellness after being in the sun? Y/N
Genitourinary: / Psoriasis? Y/N
Lesions/ulcers on your genitals? Y/N / Excessive mottling of the hands or legs? Y/N
Abnormal vaginal/penile discharge? Y/N / Skin ulcers? Y/N
Burning pain/foul odor with urination? Y/N / Any nail changes? Y/N
Blood in your urine/tea-colored urine? Y/N / Neurological:
Kidney Stones? Y/N / Tingling/numbness in face, hands or feet? Y/N
(females) Vaginal dryness? Y/N / New or worsening headache? Y/N
Musculoskeletal: / Seizures? Y/N
Joint pain? Y/N / Weakness in face/hands or feet? Y/N
Visible joint swelling? Y/N / Slurred speech that resolves? Y/N
Morning stiffness lasting more than one hour? If so, how long does it last for? Y/N / Psychiatric:
Muscle weakness? Y/N / Depression/anxiety? Y/N
Hallucinations? Y/N
Feelings that you want to end your life, or hurt or kill another person? Y/N

Do you have any other symptoms that you would like to discuss with us today?