authorization for the release of information

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Sex / sexo:
Marital status / estado civil:

(Whitch hand do you sign your name with ?)
Patient name
1
Physician initials

PAST MEDICAL HISTORY historia clínica

* Do you now have or did you ever have (¿Tiene actualmente o ¿alguna vez te han): * check if “yes” (comprobar si sí)
Any previous fractures?
Cualquier fracturas anteriores?
Any other serious injuries?
Cualquier otra lesiones graves?

RHEUMATOLOGIC (ARTHRITIS) HISTORY reumatológicos (artritis) historia

* At any time have you or a blood relative had any of the following? (check if “yes”)
* ¿Usted o un pariente Ha tenido alguna vez alguna de las siguientes condiciones? (comprobar si sí)
Arthritis unknown type / Artritis tipo desconocido
Osteoarthritis / Artrosis
Rheumatoid arthritis / artritis reumatoide
Gout / Gota
“SLE” or Lupus
Ankylosing spondylitis / Espondilitis anquilosante
Childhood arthritis / Infancia artritis
Sjogren’s syndrome / Síndrome de Sjögren
Osteoporosis
Psoriatic arthritis / Artritis psoriásica
Fibromyalgia / Fibromialgia

FAMILY HISTORY historia familiar

Father /padre
Mother /madre
Patient name
2
Physician initials

PERSONAL HISTORY historia personal

* What is your highest educational level? ¿Cuál es su nivel de enseñanza más alto?
* Are you currently working? ¿Usted está trabajando actualmente?
* If not working, are you: Si no, es usted:
* Do you receive disability or SSI? ¿Esta usted desabilitado o SSI?
Do you smoke? ¿Usted fum
How much? ¿Cuánto?
* Do you drink alcohol? ¿Usted bebe alcohol?
* Has anyone ever told you to cut down on your drinking? ¿Alguien le ha dicho que tiene que beber menos?
* Do you get enough sleep at night? ¿Usted consigue bastante sueño en la noche?
* Do you use drugs for reasons that are not medical? ¿Usted utiliza las drogas por las razones que no son médicas? (copy)
Do you wake up feeling rested? ¿Usted se despierta sintiendose descansada/o?

PREVIOUS SURGERIES / OPERATIONS cirugías anteriores

MEDICATIONS medicamentos

Patient name
3
Physician initials

SYSTEMS REVIEW

Result of last TB (PPD) test:
GENERAL
MUSCLE/JOINTS/BONES
EARS
EYES
MOUTH
NOSE
THROAT
NECK
HEART AND LUNGS
STOMACH AND INTESTINES
NERVOUS SYSTEM
PSYCHIATRIC
OSTEOPOROSIS
BLOOD / IMMUNE
SKIN
KIDNEY/URINE/BLADDER
For women only:
Have you reached menopause?
Have you had hormones?
If you are still having periods: Are they regular?
Patient name
4
Physician initials

We’re closing Our Fragmington Office!

We are closing our Farmington Office location and will see all appointments at the Manchester office starting 1 September, 2025.

All Farmington appointments will remain at current scheduled date and time, but the location will change to our Manchester Office.