First Visit Form

Only complete this form if this will be your first visit. All other patients need to use THIS FORM for review patients.

Fields marked with an asterisk (*) are required.

Part 1 - Personal Details

Part 2 - Medical Information

Medical History - please check any of the following specific conditions you have had in the past or still have. We will discuss these at your appointment.
Smoking and alcohol
Drug allergies
Medications
Previous surgeries

Part 3 - Symptoms and function

Dressing and Grooming

Over the past week...

Arising

Over the past week...

Eating

Over the past week...

Walking

Over the past week...

Hygiene

Over the past week...

Reach

Over the past week...

Grip

Over the past week...

Activities

Over the past week...
Please check any aids or devices that you usually use for any of these activities
Please check any categories for which you need help from another person.
List aids and devices you usually use for any of these activities.

Compared to 6 months ago, is your ability to manage aspects of daily life

Function is...

How long does early morning stiffness last? (mins)

How do you rate your pain on a scale of 10 (in the last 7 days)? 0 is no pain, 10 is the worst pain you can imagine.
0
How do you rate your fatigue on a scale of 10 (in the last 7 days)? 0 is no fatigue, 10 is the worst fatigue you can imagine.
0
How active has your arthritis been in the LAST 24 HOURS? Zero is NOT active, 10 is the most active it could ever be.
0