|Rheumatology Referral Information for PCP (Primary Care Providers)
A rheumatologist (roo-mah-TAH-lo-jist) is a medical specialist in musculoskeletal disorders who diagnoses and treats arthritis and other diseases of
the joints, muscles and bones. There are more than 100 types of these diseases, including rheumatoid arthritis, osteoarthritis, gout, lupus,
osteoporosis, fibromyalgia and tendonitis. Most often, a patient is referred to a rheumatologist by his primary care physician after presenting
symptoms of swelling and pain in joints, muscles and bones.
Early Inflammatory Arthritis Referral Form: RA, Lupus (SLE)
Rheumatoid Arthritis (RA) and lupus (SLE) are examples of chronic, inflammatory arthritis conditions that cause swelling of the joints and
can eventually lead to PERMANENT joint damage, deformity and disability. Your primary care doctor is concerned that you may have
an inflammatory arthritis, like rheumatoid arthritis or lupus, based upon the following symptoms:
□ You have more than 3 tender or swollen joints (hands, wrists or feet) that has persisted over the past month.
□ You have more than 30 minutes of morning stiffness (time it takes for your joints to limber up in the AM). Patients with
inflammation arthritis often use warm water or stretching exercises to loosen their joints up in the morning.
□ You have had “abnormal” blood tests (RF, anti-CCP, ANA) or x-rays demonstrating an inflammatory arthritis in the past.
□ You are concerned that you may have RA or lupus. (You have a family history of RA or lupus)
□ You have been previously diagnosed with RA or SLE (lupus) by Dr ____________________________
□ Other notes: ______________________________________________________________________________________
Inflammatory Low Back Pain (Spondylitis)?
Low back pain is a common symptom that affects most adults at some point in their lives. Most cases of low back pain are due to
muscular strains or degenerative joint disease (DJD). Less common forms of arthritis are inflammatory in nature and present with
different symptoms and are usually more debilitating. Your PCP is concerned you may have an inflammatory spondylitis (back pain
syndrome) based upon the following symptoms:
□ You have had low back pain or stiffness starting BEFORE the age of 40, which persists, even intermittently, today.
□ You have at least 30 minutes of morning stiffness (time it takes for your joints to limber up in the AM). Patients with inflammation
arthritis often use warm water, heat, chiropractors or exercises to loosen their joints up in the morning.
□ You notice your low back pain or stiffness more in the morning, or after periods of inactivity (like after a long car ride), and it
improves with stretching exercises, heat or a warm shower.
□ You have also been diagnosed with iritis/uveitis, psoriasis, Crohn’s disease/colitis or dactylitis (sausage digits) in the past.
Ophthalmologist: Dr _____________________________________________________
Dermatologist: Dr ______________________________________________________
Gastroenterologist: Dr ___________________________________________________
Podiatrist: Dr __________________________________________________________
□ Other notes: ________________________________________________________________________________________
assessment of their inflammatory arthritis signs & symptoms. Dr Shibuya will assess your patient within
3-4 weeks of receipt of these completed forms.
Arthritis, Osteoporosis, and Auto-Immune Diseases
Barry Shibuya M.D. and Christine Elias M.D.