Edmonton
Rheumatology
 
1) Physician Name:
Past Medical History
16) Use the space below to add any other details you feel are important for your rheumatologist to know:
3) Patient Name:
4) Patient Date of Birth:
5) Patient Phone Number:
2) Date of Appointment
Other Information
7) What other medical conditions do you have?
9) Do you have any allergies?
13) Do you smoke?
    
     Have you ever been a smoker?

     How much do you smoke? 
10) Are your immunizations up to date?
12) What is your drug insurance coverage (company and amount covered? (Note: This does not affect treatment provided.)
8) Please list all your medications (with doses), including vitamins & natural products, and any medications you have used in the last 3 months and stopped.
Identifying Information
15) In what city do you live?  Who lives at home with you?  What do you do for a living? 
11) Do you have any immediate family members who have Arthritis, Lupus, psoriasis, Crohn's or colitis, or uveitis?  Family Members who regularly see a rheumatologist?
14) How often do you drink alcohol?
6) Patient Email Address:
Submit your information to your rheumatologist prior to your appointment.  Use the online form below only if your rheumatologist is at the University of Alberta site.
All other patients, please click here.
Rheumatology First Appointment Form
Notes:
1) This webpage is only for patients seeing rheumatologists at the University of Alberta Hospital site. Click here if you are seeing another rheumatologist, or print the form using the link below and bring it with you to your first appointment.

2) While your information does not remain on the website, this service is not considered completely secure. If you have any concerns releasing the requested information over the internet, please print the sheet using the link below and bring it to your appointment with you.
   Appointment Time