Rheumatology New Patient Consultation Form
Patient Information
First Name
Last Name
Date of Birth
Sex
Female
Male
Other
Phone
Email
Reason for Visit
Please describe the reason for your consultation
Symptoms
Current symptoms (e.g., pain, swelling, stiffness)
When did your symptoms begin?
Which joints or areas are affected?
What makes your symptoms better or worse?
Medical History
Current medical conditions
Previous surgeries or hospitalizations
Previous rheumatologic diagnosis
Medications
List all current medications (include dosage and frequency)
Allergies (medications, foods, etc.)
Family History
Family history of autoimmune or rheumatic diseases
Social History
Occupation
Tobacco use
Alcohol use
Other relevant social history