Lake Rheumatology: Dr. K. Stark & Dr. N. Blum

Available Forms

#1 New Patient Information #2 Medication List & Drug Allergy List #3 Consent for Non-Face to face "Virtual" Visits #4 Comprehensive Patient History Questionnaire #5 Labs And Prescription Policy #6 Patient Call List #7 No Show Fee Financial Agreement #8 Rapid Questionnaire-Only if instructed #9 Osteoporosis Questionnaire

#4 Comprehensive Patient History Questionnaire

Kenneth Stark MD, PA

Date *

Name *

Date of Birth *

Do you have any of the following:

Hypertension

Diabetes

Stomach Ulcers

Cancer

Stroke

Osteoporosis

Other

Any family history of:

Rheumatoid Arthritis

Systemic Lupus (SLE)

Spondylitis

Gout

Psoriasis

Osteoarthritis

Osteoporosis

Other

List Hospitalizations and Surgeries

Smoker Status *

Occupation:

Retired?

Yes

Number of Children:

Any Miscarriages?

Yes

Abnormal Menstrual Cycle

Yes

Are you post menopausal? at what age

DO YOU HAVE ANY OF THE FOLLOWING? IF SO, CHECK THE BOX

General

Weight Los

Fatigue

Fever/Chills

Insomnia

Nervous System

Headaches

Seizures/Epilepsy

Numbness/Tingling

Muscle Pain

Muscle Weakness

Ears

Ear ringing

Loss of Hearing

Eyes

Dry eyes

Conjunctivitis

Nose

Nosebleeds

Loss of Smell

Mouth

Dry Mouth

Mouth Ulcers

Throat

Hoarseness

Difficulty Swallowing

Neck

Swollen Glands

Thyroid Disease

Heart

Chest Pain

Heart Murmur

Ankle Swelling

Lung

Cough

Night Sweats

Short of Breath

Stomach & Intestines

Heartburn

Abdominal Pain

Nausea/Vomiting

Diarrhea

Constipation

Blood in Stool

Yellow Jaundice

Kidney/Bladder

Burning while Urinating

Kidney Stones

Discharge Penis/Vagina

Difficulty Urinating

Prostate Trouble

Vaginal Dryness

Blood in Urine

Sexual Difficulties

Blood

Easy Bruising

Anemia

Skin

Rash

Sun Sensitivity

Hair Loss

Hives

Cold Induced Finger color Changes

Skin Tightening

Dandruff

Psoriasis

Fingertip Ulcers

Psychiatric

Depression

Forgetful

Psychiatric Problems

Joints

* Required field