First Appointment Information Form

Submit your information to your rheumatologist prior to your appointment. An appointment cannot be made through this service.

If you are a rheumatologist and would like to use this service, please submit a request through the “Ask the Rheumatologist” platform using the link above and provide your contact information.

Comments
This field is for validation purposes and should be left unchanged.
Identifying Information
1. Physician Name*
2. Date of Appointment*
MM slash DD slash YYYY
3. Appointment Time*

: Hours

Minutes

AM/PM
4. Patient Name (Legal First & Last Name)*
5. Patient Date of Birth*
6. Patient Phone Number*
7. Patient Email Address
Past Medical History
8. a) Do you smoke?
8. b) Have you ever been a smoker?
8. c) How much do you smoke?
9. a) How often do you drink alcohol?
10. What other medical conditions do you have?*
11. Do you have any immediate family members who have Arthritis, Lupus, psoriasis, Crohn's or colitis, or uveitis? Family members who regularly see a rheumatologist? Please list them and their condition.*
12. Do you have any allergies? If yes, what happens?*
13. Please list all your medications (with doses), including over the counter medications, vitamins & natural products, and any medications you have used in the last 3 months and stopped.*
14. Are your immunizations up to date?
Other Information
15. What is your drug insurance coverage (company and amount covered)?
(Note: This does not affect treatment provided.)
16. Who lives at home with you? What do you do for a living?
17. Use the space below to add any other details you feel are important for your rheumatologist to know:

First Appointment Information Form

Identifying Information

Past Medical History

Other Information