New Patient Forms
Street Address
City
Zip Code
Please fill out this
entire
form and
Initial
in spaces
given your initials to confirm acknowledgment.
given your initials to confirm acknowledgment.
- Describing your rights and choices and our uses and disclosures.
Northwest Rheumatology Intake Form For New Patients
Please list what medications/vitamins/supplements you are currently taking, including OVER THE COUNTER (we can photocopy a list if you have brought one with).
| Medication name and dose | Frequency | Reason |
|---|---|---|
Please tell us of any ALLERGIES, PAST medications, or medication REACTIONS (INCLUDE OVER THE COUNTER).
Please take a moment to fill out our questionnaires. Thank you!
| Please (X) the ONE best answer for your abilities at this time: | RAPID 3 | |||
|---|---|---|---|---|
| Over the last WEEK were you able to: | Without Any Difficulty |
With Some Difficulty |
With Much Difficulty |
Unable To Do |
| Dress yourself, including shoe laces and buttons? | (0) | (1) | (2) | (3) |
| Get in and out of bed? | (0) | (1) | (2) | (3) |
| Lift a full cup or glass to your mouth? | (0) | (1) | (2) | (3) |
| Walk outdoors on flat ground? | (0) | (1) | (2) | (3) |
| Wash and dry your entire body? | (0) | (1) | (2) | (3) |
| Bend down to pick up clothing off the floor? | (0) | (1) | (2) | (3) |
| Turn faucets on and off? | (0) | (1) | (2) | (3) |
| Get in and out of a car, bus, or airplane? | (0) | (1) | (2) | (3) |
| Walk 2 miles if you wish? | (0) | (1) | (2) | (3) |
| Participate in sports and activities as you’d like? | (0) | (1) | (2) | (3) |
| Get a good night’s sleep? | (0) | (1) | (2) | (3) |
| Deal with feelings of anxiety or being nervous? | (0) | (1) | (2) | (3) |
| Deal with feelings of depression or feeling blue? | (0) | (1) | (2) | (3) |
| How much pain have you had because of your condition over the past week? Please indicate how severe. | ||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No Pain | Worst Pain Possible | |||||||||||||||||||||
| 0 | 0.5 | 1 | 1.5 | 2 | 2.5 | 3 | 3.5 | 4 | 4.5 | 5 | 5.5 | 6 | 6.5 | 7 | 7.5 | 8 | 8.5 | 9 | 9.5 | 10 | ||
| Considering all the ways in which illness and health condition may affect you at this time, please circle how you are doing. | ||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No Pain | Worst Pain Possible | |||||||||||||||||||||
| 0 | 0.5 | 1 | 1.5 | 2 | 2.5 | 3 | 3.5 | 4 | 4.5 | 5 | 5.5 | 6 | 6.5 | 7 | 7.5 | 8 | 8.5 | 9 | 9.5 | 10 | ||
| Please (X) the ONE best answer for your abilities at this time: | HAQ II | |||
|---|---|---|---|---|
| Over the past WEEK were you able to: | Without Any Difficulty |
With Some Difficulty |
With Much Difficulty |
Unable To Do |
| Stand up straight from a chair? | (0) | (1) | (2) | (3) |
| Walk outdoors on flat ground? | (0) | (1) | (2) | (3) |
| Get on/off the toilet? | (0) | (1) | (2) | (3) |
| Reach and get down a 5-pound object (such as a bag of sugar) from just above your head? | (0) | (1) | (2) | (3) |
| Open car doors? | (0) | (1) | (2) | (3) |
| Do outside work (such as yard work)? | (0) | (1) | (2) | (3) |
| Wait in line for 15 minutes? | (0) | (1) | (2) | (3) |
| Lift heavy objects? | (0) | (1) | (2) | (3) |
| Move heavy objects? | (0) | (1) | (2) | (3) |
| Go up 2 or more flights of stairs? | (0) | (1) | (2) | (3) |
