Medication History Form

Name
First Last
OSTEOPOROSIS
Osteoporosis:
Please check any of the following medications you currently take or have taken.
- Fosamax
- Boniva
- Relcast
- Actonel
- Prolia
- Forteo
- Tymlos
- Evista
- Other
Other
Reason for Discontinuation
RA / INFLAMMATORY ARTHRITIS
Non Biologic DMARDS:
Please check any of the following medications you currently take or have taken.
- Methotrexate
- Plaquenil
- Arava
- Sulfasalazine
- Xeljanz
- Other
Biologic DMARDS::
Please check any of the following medications you currently take or have taken.
- Humira
- Enbrel
- Remicade
- Simponi
- Cimzia
- Actemra
- Kevzara
- Rituxan
- Orencia
- Other
Other
Reason for Discontinuation
LUPUS
Lupus:
Please check any of the following medications you currently take or have taken.
- Plaquenil
- Azathioprine
- Cellcept
- Benlysta
- Cytoxan
- Other
Other
Reason for Discontinuation
PSORIASIS / PSORIATIC ARTHRITIS
Psoriasis / Psoriatic Arthritis:
Please check any of the following medications you currently take or have taken.
- Stelara
- Taltz
- Cosentyx
- Tremfya
- Other
Other
Reason for Discontinuation
FIBROMYALGIA
Fibromyalgia:
Please check any of the following medications you currently take or have taken.
- Cymbalta
- Neurontin
- Lyrica
- Savella
- Amitriptyline
- Nortiptyline
- Other
Other
Reason for Discontinuation
Other Medications
Have you ever been treated with prednisone?
- Yes
- No
If yes, for how long?
Was it helpful?
- Yes
- No
What other pain medications such as NSAIDS (ibuprofen, naproxen, meloxicam), Celebrex, Opiates (tramadol, oxycodone, hydrocodone, Butrans) have you been treated with? What was your response to these other pain medications ?
Important Dates
Please note the date of your most recent:
PCP Visit:
Date Format: MM slash DD slash YYYY
Eye Exam:
Date Format: MM slash DD slash YYYY
DEXA Scan:
Date Format: MM slash DD slash YYYY
Flu Vaccine:
Date Format: MM slash DD slash YYYY
Pneumo Vaccine:
Date Format: MM slash DD slash YYYY
TB Test:
Date Format: MM slash DD slash YYYY

Footer

Specialties/Services we offer

Joint injections
General rheumatology
Osteoporosis
Osteoarthritis (joint pain)
Inflammatory arthritis
(including rheumatoid, psoriatic, etc.)
Lupus
Lyme Disease
Vasculitis
Fibromyalgia
Complex Arthritis Problems

Specialties/Services we offer

Musculoskeletal Ultrasound
Viscosupplementation for knee arthritis
Clinical research trials
Bone density
Vertebral fracture analysis
Body composition analysis
(body fat, lean muscle mass)
X-rays
Infusions
Lab draws

Contact Information

Emkey Arthritis & Osteoporosis Clinic
and Osteoporosis Clinic, PC

1200 Broadcasting Road
Suite 200
Wyomissing, PA 19610

(office) 610-374-8133
(Billing) 855-326-7251
(fax) 610-375-1206
Email: contact@emkeyarthritis.com

OSTEOPOROSIS

RA / INFLAMMATORY ARTHRITIS

LUPUS

PSORIASIS / PSORIATIC ARTHRITIS

FIBROMYALGIA

Other Medications

Important Dates

Footer

Specialties/Services we offer

Specialties/Services we offer

Contact Information