New patient intake

New Patient Intake — Patient History Form

Comprehensive patient history — biographical information, symptoms, systems review, medical history, family history, medications, ADLs and HIPAA / financial acknowledgements.

About this form

This is the complete new-patient intake adapted from the American College of Rheumatology Patient History Form. It takes most patients 20–30 minutes — save your progress as you go. The more we know in advance, the more focused we can keep your visit. All information you submit is encrypted in transit and only seen by our clinical team.

About 25 minutes

Progress

Patient information

Required for your chart. Please use your legal name as it appears on your insurance card.

Patient full name *Date of birth *First appointment date (if known)First appointment time (if known)Age

Sex

FemaleMaleOther / prefer to specify

Street address (Apt #) *City *State *ZIP *Home phoneWork phoneCell phone

Present illness

Please describe what brings you in today.

Describe your present symptoms *

Pain locations

Tap any area on the body or hands where you have pain.

RightFrontLeft

LeftBackRight

Right handHands · palmar viewLeft hand

Click or tap any body region or finger to mark pain. Tap again to remove. Use the notes field below for anything the diagram can’t capture.

Additional notes on pain locationsUse this space for anything the body diagram above can't capture — for example, deep vs. surface pain, how it radiates, or specific finger joints.Approximate date symptoms beganDiagnosis (if known)Previous treatment for this problem (physical therapy, surgery, injections — medications are listed later)Other practitioners you have seen for this problem

Recent preventive screening

Approximate dates if you remember — leave blank if unsure.

Date of last mammogramDate of last pap examDate of last chest X-rayDate of last tuberculosis testDate of last colonoscopyDate of last bone densitometry (DEXA)

Systems review — Constitutional & general

Check any problems that have significantly affected you.

For women only

If this section doesn't apply to you, skip it.

Age when periods began

Are your periods regular?

YesNoN/A — post-menopausal

How many days apart?Date of last period

Any bleeding after menopause?

YesNoN/A

Number of pregnanciesNumber of miscarriages

Previous surgeries

List each surgery you've had with approximate year and reason.

Surgery 1 — type, year, reasonSurgery 2 — type, year, reasonSurgery 3 — type, year, reasonSurgery 4 — type, year, reasonSurgery 5 — type, year, reasonSurgery 6 — type, year, reasonSurgery 7 — type, year, reason

Any previous fractures?

YesNo

If yes — describe

Any other serious injuries?

YesNo

If yes — describe

Medications

Do you have drug allergies?

YesNo

If yes — please list drugsType of reaction(s)Present medications — list everything you take, including aspirin, vitamins, laxatives, calcium and other supplements. Include name, dose (strength and pills per day), and how long you've taken it.

Activities of daily living

Help us understand your daily function.

Do you have stairs to climb at home?

YesNo

If yes — how many?How many people in your household?Relationship and age of each household memberWho does most of the housework?Who does most of the shopping?Who does most of the yard work?

Most of the time, I function:

HIPAA acknowledgement

Sierra Rheumatology's HIPAA Notice of Privacy Practices describes how your protected health information may be used and disclosed, including for treatment, payment, and healthcare operations. You may request a copy at any time. You have the right to inspect, request restriction on, or request an accounting of disclosures of your information. The full notice is available on our website and at the front desk.

I have received and reviewed the Sierra Rheumatology HIPAA Notice of Privacy Practices. *

Yes, I acknowledge

Financial policy

As a courtesy, Sierra Rheumatology verifies your benefits with your insurance company. A quote of benefits is not a guarantee of payment — your claim will process according to your plan. Your claim processes differently from the benefits we were quoted; the insurance company will side with the plan, not us. The benefit quote we received is not the final benefit. It is the policy of Sierra Rheumatology that payment is due at the time of service unless other financial arrangements are made in advance. We require all patients to pay their deductible, copay and/or coinsurance payment at the beginning of each visit. At the conclusion of your visits with us, you may be billed for any outstanding balances. There is a $25.00 fee for any check returned by your bank.

I have read and understand the financial policy for payment and fees. *

Yes, I agree

Medicare patients only — I request payment of authorized Medicare benefits be made on my behalf to Sierra Rheumatology. I authorize any holder of medical information about me to release information to CMS or its agents, including Sierra Rheumatology.

Yes (only check if you are a Medicare patient)

Medicare number (if applicable)Name of beneficiary / policy holder (if applicable)

Sign & submit

Patient signature *Sign with your finger, mouse or trackpad in the box below.

Sign here with your finger, mouse or trackpad

Your signature will appear on the exported PDF.

Date signed *Email address (so we can confirm receipt) *

Acknowledgement. By submitting this form, I certify that the information I've provided is true and complete to the best of my knowledge. I understand my provider will use this information to make care decisions and may follow up with me before my visit to clarify any item.

Submitting transmits this form securely to our office. Export to PDF works even with partial answers — useful if you want a printed copy to bring in. For urgent medical issues, please call our office or 911.

Trouble with the form?

Call our office and we'll either walk you through it or send a paper version.

Call (916) 677-4744 ← All forms