First Visit Form Old

First Name *

Last Name *

Middle Initial

Date of Birth *

Day of Birth *

Month of Birth *

Year of Birth *

Email

Home Phone

Cell Phone

Address *

City *

Postal Code

Are you on disability?

Yes

No

Occupation

Relationship status

Heart disease or angina

Lung disease e.g. asthma, COPD

Thyroid disease

Osteoporosis

Liver disease e.g. hepatitis

High blood pressure

Psoriasis

Diabetes

Crohn's or colitis

Blood clot (thrombosis)

Stomach ulcer

Kidney disease

Alcohol history

No, I do not drink alcohol

Yes, I drink alcohol

Number of alcoholic drinks per week

Smoking history

Never smoked

Used to smoke

I currently smoke

Number of cigarettes per day

Do you have any allergies to drugs?

Yes

No

Are you on any medications?

Yes

No

Have you had any surgeries?

Yes

No

Dressing and Grooming

Over the past week...

Were you able to dress yourself, including tying shoelaces and doing buttons?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Shampoo your hair?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Arising

Over the past week...

Were you able to stand up from an armless chair?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to get in and out of bed?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Eating

Over the past week...

Were you able to cut your meat?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to lift a full cup or glass to your mouth?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to open a new milk carton?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Walking

Over the past week...

Were you able to walk outdoors on flat ground?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to climb up five steps?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Hygiene

Over the past week...

Were you able to wash and dry your entire body?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to take a tub bath?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to get on and off the toilet?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Reach

Over the past week...

Were you able to reach and get a 5lb object (e.g. bag of sugar) from just above your head?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to bend down and pick up clothing from the floor?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Grip

Over the past week...

Were you able to open car doors?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to open jars which have been previously opened?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to turn faucets on and off?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Activities

Over the past week...

Were you able to run errands and shop?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to get in and out of a car?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to do chores such as vacuuming, yard work?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Cane

Walker

Crutches

Wheelchair

Devices used for dressing, e.g. button hook

Built-up or special utensils

Special or built-up chair

Other

Dressing and grooming

Eating

Arising

Walking

Raised toilet seat

Bathtub seat

Bathtub bar

Long handled appliance in bathroom

Long handled appliance for reach

Jar opener

Hygiene

Errands and chores

Gripping and opening things

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

Function is...

Better

Same

Worse

0

Send me a copy of this completed form

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

Arising

Eating

Walking

Hygiene

Reach

Grip

Activities

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

How long (in minutes) does your morning stiffness last from the time you wake up? (0 is no stiffness, 120 is 2+ Hours)

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.

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.

How active has your arthritis been in the LAST 24 HOURS? Zero is NOT active, 10 is the most active it could ever be.

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