Bellingham Arthritis & Rheumatology Center

History is probably the most important of a diagnostic evaluation. Certain background information is necessary. Please fill out this worksheet. If you are unsure about something, we will discuss it during your appointment. Thank you.

Patient Name Age Date Reason for today's visit If you had had the following, check the accompanying box. If you have any of the following symptoms, please check the accompanying box. Have you noticed any change in height? Have you noticed any change in weight? If yes, check accompanying box How many pounds? Are you allergic to any medications? If yes, please list Have you had any operations? If yes, what kind, when and where? Any other operations? If yes, for what reason, when and where? Occupation:

Health Maintenance

Immunization History

Pneumovax (pneumonia shot) Year pneumovax vaccine: Shingles: Year given: Tetanus booster: Year given: Flu shot Year given: Date of last Colonoscopy: Past or current tobacco use? If yes, how much?/When quit? Do you drink? If yes, how much? Past or current recreational drug use? Do you have a family history of any illness such as gout, diabetes, high blood pressure, arthritis, cancer, rheumatoid arthritis, lupus, psoriasis, scleroderma, muscle disease, heart disease, or inflammatory bowel disease?

Females:

How many pregnancies? How many children do you have? Number of miscarriages: Any trouble with pregnancies? Date of last menstrual period: Date of last Pap? Result: Date of last Mammogram: Result: