Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Rheumatology Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Primary Rheumatologic Concern
Joint Pain & Swelling Map
Morning Stiffness Duration
Autoimmune Symptom Screening
Additional details
Fatigue & Systemic Symptoms
Prior Rheumatologic Labs
Imaging History
Current Rheumatology Medications
| Medication | Dose | How often |
|---|---|---|
Biologic Therapy History
Functional Limitations
- Walking
- Sitting
- Standing
- Lifting
- Sleeping
- Climbing Stairs
- Driving
- Work Activities
Family Autoimmune History
Consent & Signature
Date
Rheumatology Intake Form template from formisoft.com. formisoft.com/intake-templates/rheumatology-intake