New Patient Form

Patient History

Date of first appointment

Time of appointment

Birthplace

Last name *

First name *

Middle initial

Maiden name

Date of birth *

Age

Sex

Street address *

Apartment #

City *

State *

ZIP code *

Home phone *

Work phone

Name of person making referral

Physician providing your primary medical care

Do you have an orthopedic surgeon?

YesNo

If yes, name

Briefly describe your present symptoms

Date symptoms began (approximate)

Diagnosis given

Previous treatment for this problem (physical therapy, surgery, injections; list medications later)

Other practitioners you have seen for this problem

Rheumatic Disease (Arthritis) History

Check if you (Yourself) or a blood relative has ever had any of the following, and note the relative's name / relationship.

Other arthritis conditions

Tap each area where you have had pain over the past week (front, back, and both hands). Tap again to remove.

Front

Back

Left hand

Right hand

Selected pain areas: None selected

Additional notes about your pain (optional)

Review of Systems

Check any problems that have significantly affected you.

Musculoskeletal & Constitutional

Morning stiffness lasts how long? (minutes/hours)

Joints affected in the last 6 months

Recent weight change amount

Eyes

Ears, Nose, Mouth & Throat

Dermatology

Psychiatric

Gastrointestinal

Genitourinary

Respiratory

Cardiovascular

Neurological

Endocrine, Hematologic & Allergic

For women only

Vaginal drynessVaginal dischargeBleeding after menopause

Age of first period

Regular periods?

YesNo

Date of last period

Date of last Pap smear

Number of pregnancies

Number of miscarriages

For men only

Discharge from penisProstate trouble

Please give the date of your last

Bone densitometry

Mammogram

Eye exam

Chest x-ray

Tuberculosis test

Flu vaccine

Pneumonia vaccine

Tetanus vaccine

Shingles vaccine

Hepatitis B vaccine

Past Medical History

Have you ever been diagnosed with any of the following? Check all that apply.

Other significant illness (not listed above)

Previous operations / surgical history

Type

Year

Reason

Type

Year

Reason

Type

Year

Reason

Previous fractures? Describe

Other serious injuries? Describe

Family History

Father - if living: age & health

Father - if deceased: age & cause

Mother - if living: age & health

Mother - if deceased: age & cause

Number of sisters

...living

Number of brothers

...living

Number of daughters

...living

Number of sons

...living

Health of children

Close blood relative (parent, sibling, or child) who has or had (check all that apply):

Relationship(s) for the conditions checked above

Social History

Spouse/significant other (alive/deceased & age)

Major illnesses of spouse

People in household

Relationship and age of each

Education (highest level)

Occupation

Hours worked per week (average)

Do you drink caffeinated beverages?

YesNo

Cups/glasses per day

Do you smoke?

NoYesPrevious smoker

Amount per day / how long ago quit

Do you drink alcohol?

YesNo

Number per week

Has anyone told you to cut down on drinking?

YesNo

Recreational drug use?

YesNo

If yes, please list

Do you exercise regularly?

YesNo

Frequency / describe

Medications

Drug allergies?

YesNo

If yes, to what?

Type of reaction

Present medications (include OTC, aspirin, vitamins, supplements)

Name of drug

Dose / pills per day

How long taken

Helped?

Name of drug

Dose / pills per day

How long taken

Helped?

Name of drug

Dose / pills per day

How long taken

Helped?

Past medications

Check any you have taken, how much they helped, and any reactions.

NSAIDs

Pain relievers

Corticosteroids

DMARDs

Biologics

Osteoporosis

Gout

Others

Have you participated in any clinical trials for new medications? If yes, list

Activities of Daily Living

Who does most of the housework?

Who does most of the shopping?

Who does most of the yard work?

Because of health problems, do you have difficulty with the following? Choose one per row.

What is the hardest thing for you to do?

Overall, how have you felt this past week? (very good to very poor)

Unusual fatigue this past week (0 = none, 10 = major)

Pain this past week (0 = none, 10 = worst)

Patient Information Update

Full name *

Preferred language

Date of birth *

Social Security Number *

Address *

City *

State *

ZIP code *

Phone number *

Alternate number

Email *

Preferred contact method

CallTextEmailPatient portal

May we leave a detailed voicemail?

YesNo

May we text detailed information?

YesNo

Emergency contact name *

Emergency contact phone *

Relationship *

Employer

Job title

Work phone

Occupation / duties

Preferred pharmacy

Specialty pharmacy

Preferred lab

Insurance

Primary insurance *

If you have an HMO plan, a CURRENT referral from your PCP is required every year, or your coverage will be denied and you will be self-pay.

HMO referral on file?

YesNo (self-pay)Not applicable

Member / Subscriber ID *

Policyholder name

Policyholder DOB

Secondary insurance

Member / Subscriber ID

Policyholder name

Policyholder DOB

New diagnoses in the past year

Hospitalizations or surgeries in the last year

Current medications

Known allergies

Primary care physician

Financial Agreement & Acknowledgements

Please read and check each box to acknowledge. You will sign at the bottom.

Authorized contact

A person you authorize to receive information about your care.

Name

Relationship

Phone number

Printed name *

Signature (type full name) *

Date *

Authorization for Release of Medical Records

Patient name *

Date of birth *

Phone number *

I authorize Permian Arthritis & Rheumatology Center, PLLC (8050 E. Hwy 191, Suite #203, Odessa, TX 79765; phone 432-326-1939; fax 432-224-1091) to release my protected health information (PHI) to:

Person / practice name

Phone / fax

Address

Information to be released

Other (please specify)

Purpose of disclosure

Continuity of carePersonal useInsuranceLegal

Other purpose

Records valid from

To

Authorization expires on

I may revoke this authorization in writing at any time, except where action has already been taken. My treatment, payment, or benefits will not be conditioned on signing. Information disclosed may be subject to redisclosure and may no longer be protected by federal privacy regulations. I may receive a copy of this authorization.

Patient / legal representative name *

Signature (type full name) *

Date *

If signed by a legal representative, describe authority (parent, guardian, POA)

Patient Registration

Patient information

First name *

Middle initial

Last name *

Date of birth *

Address *

City *

State *

ZIP *

Home phone *

Cell phone

Email *

Driver's License #

Social Security # *

Employer

Spouse / parent / guardian name

Person responsible for payment

Name

Date of birth

SSN

Address

Employer

Insurance

Primary insurance name

Mailing address

Policyholder name

Relationship to patient

Member ID #

Group #

Emergency contact

Name

Relationship

Phone

Payment is required at time of service. I am responsible for amounts not covered by insurance (copy fee $1.00/page). The registration information above is correct to the best of my knowledge, and I accept the payment policies. I acknowledge the Notice of Privacy Practices (HIPAA) and authorize Dr. Mukkera to furnish information to my insurance carrier and obtain records from pharmacies regarding my or my dependents' care. If prescribed a controlled drug, I acknowledge the controlled substance / triplicate prescription agreement.

Signature (type full name) *

Date *

Cancellation, Late & No-Show Policy

Effective March 16, 2026.

When patients schedule an appointment, we set aside time to provide the highest quality of care. Please contact our office at least 24 hours ahead to cancel or reschedule.

Any patient who no-shows, cancels, or reschedules without 24 hours notice will be charged a $50 non-refundable fee. Any patient more than 15 minutes late will be charged $50. We ask all patients to arrive 15 minutes early.

I have read and agree to the cancellation, late, and no-show policy.

Signature of patient (type full name) *

Printed name *

Date *

Patient History

Rheumatic Disease (Arthritis) History

Review of Systems

Musculoskeletal & Constitutional

Eyes

Ears, Nose, Mouth & Throat

Dermatology

Psychiatric

Gastrointestinal

Genitourinary

Respiratory

Cardiovascular

Neurological

Endocrine, Hematologic & Allergic

For women only

For men only

Please give the date of your last

Past Medical History

Previous operations / surgical history

Family History

Social History

Medications

Present medications (include OTC, aspirin, vitamins, supplements)

Past medications

NSAIDs

Pain relievers

Corticosteroids

DMARDs

Biologics

Osteoporosis

Gout

Others

Activities of Daily Living

Patient Information Update

Insurance

Financial Agreement & Acknowledgements

Authorized contact

Authorization for Release of Medical Records

Information to be released

Purpose of disclosure

Patient Registration

Patient information

Person responsible for payment

Insurance

Emergency contact

Cancellation, Late & No-Show Policy

Form submitted