Social History: Tobacco Use Not currently, never smoked Not currently, previously smoked Currently smoking

Social History: Alcohol Use Yes No

Family History: Do you know of any blood relative who has or had lupus rheumatoid arthritis psoriatic arthritis scleroderma Sjogren's syndrome polymyositis/dermatomyositis ankylosing spondylitis psoriasis osteoporosis fibromyalgia polymyalgia rheumatica gout osteoarthritis cancer stroke heart problems asthma bleeding tendency diabetes seizure disorder colitis tuberculosis alcoholism depression other

Do you have any of the following problems? recent weight gain recent weight loss fatigue weakness fever eye pain eye redness double or blurry vision eye dryness feels like something is in your eyes itching eyes ringing in ears loss of hearing nosebleeds dry nose sores in mouth hoarseness difficulty swallowing chest pain shortness of breath swollen legs/feet cough nausea vomiting stomach pain constipation diarrhea blood in stool black stools heartburn difficulty urination pain or burning on urination blood in urine discharge from penis/vagina vaginal dryness rash/ulcer sexual difficulties prostate troubles easy bruising hives sun sensitivity tightness hair loss color changes of hands/feet in the cold headache dizziness fainting muscle spasm loss of consciousness memory loss night sweats anxiety depression difficulty falling asleep difficulty staying asleep