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Rheumatic Disease Center

Welcome to the Rheumatic Disease Center. We look forward to seeing you soon at one of our clinics.

7080 N Port Washington Rd
Glendale, WI 53217
(414) 351-4009
2500 W Layton Ave, Suite 250
Milwaukee, WI 53221
(414) 351-4009
Appointment Information
  • Appointment Duration: Your first appointment will take approximately one hour. If the doctor requires x-rays or lab work, your visit may take longer.
  • Arrival Time: Please arrive 15 minutes before your scheduled appointment time to check in. If you arrive more than 10 minutes late, we may need to reschedule your appointment.
  • What to Bring: Bring your driver's license or other photo ID, all insurance cards, and a list of medications you are currently taking.
  • Payment: Co-payments are collected at the time of service. We accept Visa, MasterCard, Discover, American Express, and personal checks.
  • Missed Appointment Policy: If you need to cancel, please give us at least 48 hours' notice. If you have more than two (2) no-shows or late cancellations before initiation of care, rescheduling will be at the discretion of the physician group.
  • Medical Records: If you have had x-rays, EKGs, MRIs, CT scans, or lab work, please bring the results with you. If you have seen a rheumatologist, bring those records or have them faxed to 414-351-7060.
  • New patient forms: All required packet information must be completed and submitted at the time of your visit. If you have not already completed it, please plan to arrive 20 minutes early.
  • Phone Calls and Appointments: All phone calls, appointment scheduling (including for our Layton clinic), refill requests, and mailings are handled by our main office on Port Washington Road.
  • Privacy Policy: During your first visit, you will receive a copy of our privacy policy.

We look forward to seeing you soon!

Sincerely,

The Rheumatic Disease Center

John Albert, MD | Jonathan Kushi, MD | Kurt Oelke, MD

Suhail Hameed, MD | Arnold Lim, MD | Farrukh Pasha, MD | Katherine Finn, DO

Rheumatic Disease Center

Patient History Form

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* Required fields

1

Patient Information

Address
Contact Numbers
Primary Care Physician
Referral Information
Please check the box for ethnicity (the government requires us to collect this data )
2

Present Symptoms

3

Past Medical History

Please indicate if you have been diagnosed with any of the following:

Previous Rheumatological History
4

Social History

Marital Status
Lifestyle
Previous Surgeries
Procedure Year Notes
5

Hospitalizations, Family History & Drug Allergies

Previous hospitalizations other than surgeries
Reason Year Notes
Family History
If Living If Deceased
Age Health Age at Death Cause
Father
Mother
Blood Relatives — Check if applicable
Drug Allergies
Drug Name Reaction
6

Medications

Present Medications
Drug Name Dose (include strength and pills/day)
Past Medications

Are you now taking or have you ever taken:

Drug Name Dosage Length of Time A Lot Some Not at all Reactions
7

Function Assessment & Review of Systems

Daily Function Rating

Rate your overall daily performance  (1 = Very poorly   10 = Very well)

Very poorly
Very well
Pain Scale

Rate your pain level  (1 = No pain   10 = Worst pain)

No pain
Worst pain
Review of Systems

Check any problems which have significantly affected you:

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