First Appointment Information Form Submit your information to your rheumatologist prior to your appointment. Identifying Information1. Physician Name*- Select Your Rheumatologist -Dr. Stephen AaronDr. Shafiq AkbarDr. Alison CliffordDr. Tharindri DissanayakeDr. Joanne HomikDr. Niall JonesDr. Steven KatzDr. Stephanie KeelingDr. Walter MaksymowychDr. Lilia OlaruDr. Mohammed OsmanDr. Anna OswaldDr. Saurash ReddyDr. Anthony RussellDr. Dale SholterDr. Jason SooDr. Jan Willem Cohen TervaertDr. Sarah TrosterDr. Elaine YacyshynDr. Alex YanDr. Carrie Ye2. Date of Appointment* Date Format: MM slash DD slash YYYY 3. Appointment Time* : HH MM AM PM 4. Patient Name (Legal First & Last Name)* 5. Patient Date of Birth*6. Patient Phone Number*7. Patient Email Address Past Medical History8. a) Do you smoke?NoYes8. b) Have you ever been a smoker?NoYes8. c) How much do you smoke?N/A1-2 cigarettes/day5-10 cigarettes/day10-20 cigarettes/day20+ ciagarettes/dayCigars or other9. a) How often do you drink alcohol?NeverOnce or Twice per yearOnce or Twice per monthOnce or Twice per weekOnce or Twice per day10. What other medical conditions do you have?*11. Do you have any immediate family members who have Arthritis, Lupus, psoriasis, Crohn's or colitis, or uveitis? Family members who regularly see a rheumatologist? Please list them and their condition.*12. Do you have any allergies? If yes, what happens?*13. Please list all your medications (with doses), including over the counter medications, vitamins & natural products, and any medications you have used in the last 3 months and stopped.*14. Are your immunizations up to date?NoYesOther Information15. What is your drug insurance coverage (company and amount covered)?(Note: This does not affect treatment provided.)16. Who lives at home with you? What do you do for a living?17. Use the space below to add any other details you feel are important for your rheumatologist to know:NameThis field is for validation purposes and should be left unchanged.