First Appointment Information Form

Submit your information to your rheumatologist prior to your appointment. An appointment cannot be made through this service.

Identifying Information
1. Physician Name*
2. Date of Appointment*
MM slash DD slash YYYY
3. Appointment Time*

: Hours

Minutes

AM/PM
4. Patient Name (Legal First & Last Name)*
5. Patient Date of Birth*
6. Patient Phone Number*
7. Patient Email Address
Past Medical History
8. a) Do you smoke?
8. b) Have you ever been a smoker?
8. c) How much do you smoke?
9. a) How often do you drink alcohol?
10. 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?
Other Information
15. 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:
Name
This field is for validation purposes and should be left unchanged.

Identifying Information