Rheumatology Clinical Record
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New Patient
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Header
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Patient Name *
File No *
Age / Sex
Date of Visit
Occupation
Phone
1. Chief Complaint (C/O)
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2. History of Present Illness (HPI)
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3. Critical Rheumatological Screening
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A. Articular Pattern & Chronobiology
B. Connective Tissue Disease & Autoimmune Screen
C. Spondyloarthritis (SpA) & Systemic Vasculitis Red Flags
4. Social History
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Smoking
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Never
Former
Current
Alcohol
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Never
Occasional
Regular
Former
Drug Use
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None
Former
Current
Diet & Exercise Habits
5. Past Medical History
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Chronic Illnesses
Previous Hospitalization
Allergies
Current Medications
6. Past Surgical History
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Surgical History
7. Review of Systems
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8. Physical Examination
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BP (Blood Pressure)
PR (Pulse Rate bpm)
Temp (°C / °F)
SpO2 (%)
Physical Examination Notes
9. Investigations
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10. Rx (Prescription) & Plan
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