Patient Intake Questionnaire Date MM slash DD slash YYYY Name First Last Please check any of the following medical problems that apply to you(Required) Abnormal blood counts Blood Transfusion Blood Clots, Pulmonary Embolism Anaphylactic Reaction Ankylosing Dpondylitis Spondyloarthropathy Psoriatic Arthritis Aortic Aneruysm Peripheral Vascular Disease Asthma COPD Lung Fibrosis Costochondritis Bleeding from bowel, Bleeding from Stomach Cancer, Tumor, Lymphoma, Melanoma, Skin Cancer Carpal tunnel syndrome, Tarsal tunnel syndrome Celiac Disease Irritable bowel syndrome Childhood or Juvenile Arthritis Rheumatic fever Colitis, Ulcerative Colitis, Crohn disease Diabetes Diverticulitis Alcohol Addiction Drug Addiction Epilepsy/Seizure Disorder Eye Problems, Iritis, Scleritis, Uveitis, Conjunctivitis, Cataract, Macular Degeneration Fibromyalgia, Chronic fatigue syndrome Sleep Apnea Fracture History, Osteopenia, Osteoporosis, Osteomalacia, Paget's disease of the bone Frequent Infections, Pneumonia, Sepsis, Abcess Immune Deficiency Splenectomy Peptic Ulcer Disease, Gastric Reflux STDs: Gonorrhea, Herpes, Chlamydia, HIV/AIDS, Syphilis Gout, Pseudogout, CPPD Hashimoto thyroiditis, Hypothyroidism, Hyperthyroidism, Hypoparathyroidism, Hyperparathyroidism Headaches Heart Disease, Heart failure, Heart Attack, Angina, Atrial Fibrillation, Cardiomyopathy, abnormal rhythm Hepatitis B, Hepatitis C, Autoimmune Hepatitis, Liver Failure, Fatty Liver, Cirrhosis of liver Hyperlipidemia, Elevated cholesterol or triglyceride Kidney problems, kidney stones Lupus, Undifferentiated connective tissue disease, Mixed Connective tissue disease, Sjogren's Syndrome, Scleroderma, CREST Syndrome, Raynaud's Lyme Disease, Rocky Mountain Spotted Fever, Babesiosis Multiple Sclerosis, Optic neuritis, Neuromyelitis optica spectrum disorder or Devic's disease, Parkinson's disease, Stroke Myositis, Polymyositis, Dermatomyositis, Anti-synthetase syndrome Neuropathy, Numbness in hands or feet, pins and needles sensation in hands and feet Osteoarthritis, Degenerative arthritis, SAPHO syndrome Pinched nerve, Sciatica, Herniated disc, Spinal stenosis, Radiculopathy Pneumonia vaccination, Shingles vaccination, Flu vaccination, Shingles vaccination Polymyalgia Rheumatica, Temporal or Giant cell Arteritis, Palindromic Rheumatism, Episodic arthritis Positive skin test for TB (PPD), Tuberculosis, Positive T-SPOT test, Positive Quantiferon TB Gold Psychiatric Disorders, Bipolar Disorder, Depression, Anxiety Disorder, Obsessive-Compulsive Disorder (OCD), PTSD Psoriasis, Eczema, Dermatitis, Neurodermatitis, Rosacea Radiation Therapy Seropositive Rheumatoid arthritis, Seronegative Rheumatoid Arthritis Sarcoidosis Suicide Attempt Work injury Other Please check those that occur in your family.(Required) Blood Clots, Pulmonary Embolism Ankylosing Dpondylitis Spondyloarthropathy Psoriatic Arthritis Lung Fibrosis Cancer, Tumor, Lymphoma, Melanoma, Skin Cancer Celiac Disease Irritable bowel syndrome Childhood or Juvenile Arthritis Colitis, Ulcerative Colitis, Crohn disease Eye Problems, Iritis, Scleritis, Uveitis, Conjunctivitis, Cataract, Macular Degeneration Fibromyalgia, Chronic fatigue syndrome Fracture History, Osteopenia, Osteoporosis, Osteomalacia, Paget's disease of the bone Immune Deficiency Gout, Pseudogout, CPPD Hashimoto thyroiditis, Hypothyroidism, Hyperthyroidism, Hypoparathyroidism, Hyperparathyroidism Kidney stones Lupus, Undifferentiated connective tissue disease, Mixed Connective tissue disease, Sjogren's Syndrome, Scleroderma, CREST Syndrome, Raynaud's Positive skin test for TB (PPD), Tuberculosis, Positive T-SPOT test, Positive Quantiferon TB Gold Psoriasis, Eczema, Dermatitis, Neurodermatitis, Rosacea Seropositive Rheumatoid arthritis, Seronegative Rheumatoid Arthritis Sarcoidosis Psychiatric disorders, Bipolar disorder, Depression, Psychiatric disorders, Bipolar disorder, Depression, Anxiety disorder, Obsessive-Compulsive Disorder (OCD) Childhood arthritis, Ehlers-Danlos syndrome (EDS) Chronic neck or chronic back pain Other Please indicate if you had these tests. Please upload if you have any of the results.(Required) Blood Testing for Arthritis X-rays MRI Exam CT Scan Bone Scan Nerve or Muscle Testing Bone Density Testing DXA Please list past operations:(Required) Joint Replacement Spinal Surgery Cancer Surgery Gastric Bypass Total Abdominal Hysterectomy Fractures requiring Surgery Please indicate the evaluation and treatment that you had before:(Required) Physical Therapy Chiropractic Treatment Water Therapy Massage Therapy Acupuncture Please indicate if you have taken these medications Before:(Required) Methotrexate Sulfasalzine Hydroxychloroquine (Plaquenil) Leflunomide (Arava) IMURAN (azathioprine) Cyclosporine Xeljanz Olumiant Rinvoq Enbrel Humira Simponi or Simponi Aria Cimzia Actemra or Kevzara Orencia Rituxan Benlysta Skyrizi Tremfya Cosentyx Taltz Otezla Remicade Stelara Anakinra NSAIDs such as Motrin (Ibuprofen), Aleve (Naproxen), Lodine, Indocin, Sulindac, Daypro, Ansaid, Tolectin, Celebrex, Meloxicam, Voltaren (Diclofenac), Toradol (Ketorolac), Relafen (Nabumetone), Feldene, Fibromyalgia medications: Lyrica, Cymbalta, Savella, Gabapentine Osteoporosis medications: Prolia, Forteo, Tymlos, Fosamax (Alendronate), Boniva, Actonel, Reclast, Evenity Please check those that apply to you:(Required) Right Shoulder Left Shoulder Right Elbow Left Elbow Right Wrist Left Wrist Right Hand Left Hand Right Hip Left Hip Right Knee Left Knee Right Ankle Left Ankle Right Foot Left Foot Neck Middle Back Lower Back Heel Pain TMJ Please check where you usually have pain:(Required) Wight Gain Weight Loss Recent Injury Skin Rash or Hives Scalp Tenderness Visual Changes Dry Eyes Dry Mouth Ear Pain or Swelling Nose Ulcer Mouth Ulcer Cough Shortness of Breath Recurrent Diarrhea Numbness Weakness Fatigue Rash with Sun Exposure Hair Loss Discoloration of hands or feet with cold Morning Stiffness Frequent Repositioning with Sitting or Sleep Please list your current medications: Add RemovePlease list your medication allergies: Add RemoveConsent(Required) I agree to the prescription policy outlined below.Presentation Policy for TelRheum.com Policy on Prescribing Controlled Substances At TelRheum.com, our foremost priority is the well-being and safety of our patients. To uphold the highest standards of clinical care and comply with regulatory requirements, we have instituted a stringent policy regarding the prescription of controlled substances. Policy Statement: TelRheum.com does not prescribe controlled substances. This policy encompasses, but is not limited to, the following categories of medications: 1. Narcotic Analgesics: • Examples: Oxycodone, Hydrocodone, Morphine, Fentanyl, Codeine 2. Anxiolytics: • Examples: Benzodiazepines such as Alprazolam (Xanax), Lorazepam (Ativan), Diazepam (Valium), Clonazepam (Klonopin) 3. Antidepressants: • Note: While the majority of antidepressants are not controlled substances, certain medications, particularly those combined with narcotics (e.g., Buprenorphine/Naloxone), fall under this category. 4. Anticonvulsants: • Examples: Pregabalin (Lyrica), Gabapentin (Neurontin) 5. Central Nervous System (CNS) Stimulants: • Examples: Amphetamines (Adderall), Methylphenidate (Ritalin, Concerta) 6. Hypnotics: • Examples: Zolpidem (Ambien), Eszopiclone (Lunesta), Temazepam (Restoril) Rationale: • Patient Safety: Controlled substances pose risks of dependence, misuse, and significant adverse effects. Our policy prioritizes non-controlled, evidence-based treatments to safeguard patient health. • Regulatory Compliance: Adherence to local, state, and federal regulations regarding controlled substances is essential for maintaining the integrity and legality of our practice. • Quality of Care: By focusing on non-controlled treatments, we ensure a more holistic and sustainable approach to managing chronic conditions. Alternative Treatments: • For pain management, we offer a range of non-narcotic options, including referrals to physical therapy, over-the-counter analgesics, and non-opioid prescription medications. • For anxiety and depression, we advocate evidence-based interventions such as cognitive-behavioral therapy (CBT), lifestyle modifications, and non-controlled pharmacotherapy. • For sleep disorders, we recommend behavioral therapies, sleep hygiene education, and non-controlled sleep aids. • For seizure disorders, we coordinate with neurologists who can provide comprehensive management of these conditions. Patient Guidance: • Patients currently using controlled substances are advised to seek care from their primary care physician or a specialist qualified to manage these medications. • Our team is available to provide referrals and support to ensure continuity of care for patients requiring controlled substances for their health conditions. Conclusion: This policy underscores TelRheum.com’s dedication to delivering safe, responsible, and high-quality healthcare. We are committed to exploring all available non-controlled treatment options to optimally support our patients’ health and well-being. For further information or to discuss your treatment options, please contact our office directly. TelRheum.com Your Health, Our Commitment
