Global Health Survey

Page

Welcome to your Patient Survey today is September 25, 2018

 

Name Email
Height:       Weight:      Age:
Address:
Phone:

Current Status

Select any of the following joints that are afflicted:

Jaw
Neck
Chest
Lower Back
Abdomen
Shoulder
Elbow
Wrist
Fingers
Toes
Hip
Knee
Ankle
Are you currently experiencing a flare-up?
Using the diagram below, please describe where the flare ups began and what you feel triggered the flare up.

Body Diagram

Congenital Malformations

Are there malformations of your great toes?


Hearing

Do you have a hearing problem?
Has your hearing been evaluated by a hearing specialist?
Do you use a hearing aid?

Twin Sibling History

(skip if not applicable)

Is there any major functional difference between you and your twin sibling?
What difference are there between you and your identical twin?
To what do you attribute these differences?

Medical History

At what age did you experience the first symptoms of flare-ups (swelling, lumps, bumps)?
What were the first symptoms you experienced?
What diagnoses were made before the correct diagnosis was made?
When was the correct diagnosis made?
By whom was the diagnosis made?
If a biopsy was performed, where on your body was it done?
Who performed the biopsy?
How old were you at the time the biopsy was performed?
In what hospital was it performed?
Were there any treatments given after the correct diagnosis was made? (e.g., surgery, chemotherapy, radiation therapy, injections, etc.)
What effect(s) did the treatment(s) have?

Injury History

Have you had any severe injuries since birth?
Have you had any falls, fractures, or injuries that led to flare-ups?


 



Date of Injury



Describe Event



Was there a flare-up?



Did bone form?



Did you lose mobility?



Other Problems



 





















 





















 





















 





















 





















 





















 




















Immunizations & Dental History

Have you had any dental work that has led to new bone formations?
Did you lose movement in your jaw as a result of an injection or dental work?

Have you ever been given an immunization or injection(s) that has resulted in heterotopic ossification?
If so, where was the injection(s) given?
What was the result of the injection(s)?

Developmental History

Was there any change in your health status at puberty?

If so, how did it change?


Family History

MemberNameAliveDeceasedAgeCurrent Health Status or Cause of Death
Mother's Mother
Mother's Father
Father's Mother
Father's Father
Father
Mother
Sister / Brother
Sister / Brother
Sister / Brother
Sister / Brother
Sister / Brother

Social History

Occupation:
Education (last grade completed in school):
Exercise:
What type(s) of exercise do you participate in?
Do you use any of the following:
Have you had any unintentional weight loss of more than 10 pounds over the past 3 months?

Past Surgical History

Have you had any hospitalizations or operations in the past?

If so, what operations were done and when?

Hospitalizations / OperationsName of Hospital & CityYearComplications
    
    
    
     
    

Please list all other medical problems that you have:


Have you had any difficulty swallowing as a result of a flare-up?

Are you on a special diet?

If so, what kind of diet?


Medications

Name of MedicationHow much do you take?How often do you take it?How long have you been taking this medication?

Have you ever used any of the following medications? Please explain how these medications affected your condition.

Steroids? (e.g. prednisone)


Etidronate?


Non-steroidal anti-inflammatory medications? (e.g., aspirin, ibuprofen, indomethacin, vioxx, celebrex, etc.)


Accutane?


Singulair?



Allergies & Drug Reactions

Allergic ToReaction

Review of Systems

Are you currently having, or have you ever had, problems with the following?

 SystemYesNoPlease Describe
 Eyes   
Ears, Nose, Throat    
Lungs, Breathing    
Digestion, GI Problems    
Bowel, Bladder Problems   
Back Problems    
High Blood Pressure    
Bleeding Problems    
 Balance Problems   
Numbness, Tingling    
Blackout, Fainting    
Psychological Problems    
Cancer    
Arthritis    
Diabetes    
Pressure Sores    
Spinal Curvature (scoliosis)    
Epilepsy, Seizures    
Blood Transfusions    
Weight Change    
Other    


Thank you very much for your time & effort in accomplishing this survey.