ID
Appointment Date
Calendar Resource
Appointment Type
Appointment Time
Patient's Name
Vista Rheumatology Follow Up Form
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Birth
*
Email Address:
*
example@example.com- To send you a copy of this form upon completion.
Age:
*
Height:
*
Please Select
4'11
5'0
5'1
5'2
5'3
5'4
5'5
5'6
5'7
5'8
5'9
5'10
5'11
6'0
6'1
6'2
6'3
6'4
6'5
6'6
6'7
6'8
6'9
6'10
6'11
7'0
7'1
7'2
Weight
*
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Medical Information
Where do you have pain?
*
What is your pain level right now 0-10?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
(0 is none, 4-6 medium, 10 is the worst pain)
Pain Description:
*
Sharp
Dull
Shooting
Burning
Throbbing
Achy
None
Other
What aggravates your pain/condition?
*
walking
bathing
dressing
intimacy
meal prep/eating
work
positional transfer
sitting
sleeping
standing
toileting
None
Other
What relieves/alleviates your pain/condition?
*
NSAIDS
Tylenol
Steroids
Topicals
Ice
Heat
Physical Therapy
Chiropractor
Bracing
Exercise
Rest
None
Other
How long is your morning stiffness? (please specify minutes or hours)
*
What activities have IMPROVED since starting current treatment?
bathing
dressing
eating
increased range of motion
intimacy
joint swelling
joint tenderness
meal prep
sitting
sleeping
positional transfers
less analgesic use
standing
stiffness
toileting
walking
work
none
Other
Do you experience adverse reactions to any medication being prescribed by the rheumatology provider?
*
rash
welts
constipation
diarrhea
chest pain
mouth sores
respiratory distress
infection
cough
headaches
hair loss
None
Other
Have you started any new medication from other providers?
*
Yes
No
If yes, please list:
Do you experience any tingling or numbness?
*
Yes
No
If yes, please list:
Do you experience any weakness?
*
Yes
No
If yes, where?
Since your last visit did you experience any of the following?
*
Rows
Yes
No
If yes, Date:
If yes, Details:
Surgery
Infection
Hospitalizations
Injury (including falls)
Refill of Medications
Please list any medication, dose, and frequency you would like refilled or renewed at your visit today:
What pharmacy would you like us to send the medication(s) to?
*
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