Download Central Alabama Radiation Oncology

CENTRAL ALABAMA RADIATION ONCOLOGY
Patient Health History Questionnaire
Patient Name:
Birth date:
Age:
Address:
City/State/Zip:
Social Security Number:
Marital Status:
Race:
Home Phone:
Cell Phone:
Email:
Height:
Today’s date:
Male
Female
Do you have a living
Will?
Ethnicity:
Referring Physician (Please provide phone number if you have with you today)
__________________________________
Primary Care physician:
__________________________________
Surgeon:
__________________________________
Please list additional Physicians assisting with your care:
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
Reason for your visit today:
When were you diagnosed?
Do you have a PORT/VASCULAR DEVICE?
Do you have an Implanted Pacemaker or Defibrillator?
If yes, treated by
Problem
Yes
No which doctor
AIDS/HIV positive
Yes
No
Alzheimer’s
Yes
No
Arthritis
Yes
No
Asthma
Yes
No
Back Problems
Yes
No
Bone Loss(Osteoporosis)
Yes
No
Crohn’s Disease
Yes
No
Cardiac Disease or heart
Yes
No
problems
Diabetes
Emphysema or COPD
Lupus or Sceroderma
Gallstones
GERD (reflux,
heartburn)
Hepatitis
High Cholesterol
High Blood Pressure
Hypothyroid (low)or
Hyperthyroid (high)
Impotence or infertility
Kidney Disorders or stones
History of mononucleosis?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
No
No
No
Details (include approximate date of diagnosis)
History of Sexually
Yes
No
transmitted diseases?
Stroke or TIA’s
Yes
No
Please list other medical problems not listed above:
FEMALE-Do you receive regular
Yes
No
Date of last mammogram:
mammograms?
Do you receive regular Pap smears?
Yes
No
Date of last Pap smear:
MALE -Do you have regular PSA
Yes
No
Date of last PSA:
checks?
Date of your last physical exam:
SURGERIES (Provide details, including approximate dates)
EXTENDED HOSPITALIZATIONS (stays in the hospital for more than 48 hours-provide details
OBSTETRIC HISTORY (females)
Number of time pregnant:
Number of children with which
you’ve been pregnant:
Premature
births:
Abortions (spontaneous
or other):
Living Children:
ALLERGIES and OTHER ADVERSE REACTIONS
List medications you are allegoric to or to which you have had adverse reactions in the past (nausea, dizziness, etc.)
Medication
Reaction
Have you ever received intravenous contrast?
Yes
No
If you received IV contrast, did you have any problems?
Yes
No
Do you have any seafood allergies?
Yes
No
Do you have other allergies, if so to what?
Yes
No
MEDICATION HISTORY (List all Medications you are currently taking including vitamins and over the counter medications)
Name of Medication
Strength
Frequency
Reason for taking
Have you received radiation in the past?
Have you received or are you currently receiving Chemotherapy treatments?
Yes
Yes
No
No
Have you met with a Chemo doctor yet?
Chemotherapy Name
Yes
No
Frequency
FAMILY HISTORY
Mother
□ Living
Check all that apply:
□Deceased
Father
Age_____ Father
Mother
□Living
Brother
□Deceased
Sister
Hypertension
Heart Disease
Stroke
Blood Clots
Blood Disorders
Unusual Bleeding
Diabetes
Cancer (describe)
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
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Other (describe)
□
□
□
□
Age_____
SOCIAL HISTORY
Do you smoke? □Yes □No
How many years: ______
About how many packs a day:________
Have you ever smoked? □Yes □No When did you quit, if you smoked? _____ How many years did you smoke? ____
Do you ever drink alcoholic beverages? □Yes □No When did you quit?_____
What kind, how often and how much:
Other drug use, at present or in the past? □Yes □No
Describe:
Are you employed? □Yes □No
What is your occupation?
How long have you/did you work at your job(s)?
Did you ever have any chemical or other hazardous material exposure at work? □Yes □No
Describe:
REVIEW OF SYSTEMS
CONSTITUTIONAL (circle)
Appetite
YES
Fatigue
YES
Fever
YES
Weakness (sense of not feeling well)
YES
Night Sweats
YES
Rigors/chills
YES
Weight change
YES
SKIN(circle)
NO
NO
NO
NO
NO
NO
NO
Rashes
Swelling
Sores
Itching
Dryness
Color Changes (or yellowing)
FEMALES: BREAST
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
Easy bruising
Lymph Nodes
ALLERGIC/IMMUNOLOGIC
YES
YES
NO
NO
HEAD
Hair Loss
YES
*If you have been referred to us for Breast Cancer please indicate
your current Bra size (for insurance purposes only)
Breast masses
Nipple discharge
Nipple inversion
Pain
Bra size _______
YES
YES
YES
YES
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
Heart racing
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
INTEGUMENTARY
Hair Loss
Blisters
Bruising
Dry skin
Facial burning
Increased sensitivity to sun
Rash
Hives, welts, itching
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
NO
NO
NO
NO
EYES
Blurred vision
Double vision
Excessive/abnormal tear production
Night Blindness
Sensitivity to light
Visual difficulties
YES
YES
YES
YES
YES
YES
EARS, NOSE, MOUTH, THROAT
Difficulty swallowing
YES
Ear Pain
YES
Nose Bleeds
YES
Heartburn
YES
Impaired hearing
YES
Hoarseness
YES
Mouth dryness
YES
Oral bleeding
YES
Ear infections
YES
Sinusitis
YES
Mouth sores
YES
Taste altered
YES
Ringing in ears
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NECK
Masses
Muscle weakness
Pain
Limited range of motion
Swelling
YES
YES
YES
YES
YES
Abdominal Pain
Constipation
Heartburn/indigestion
Rectal bleeding
Black tarry stools
Abdominal cramping
Vomiting
YES
YES
YES
YES
YES
YES
YES
FEMALE ONLY
Burning with urination
Frequent urination
Genital masses
Blood in urine
Accidental loss of bladder or bowel
control
NO
NO
NO
NO
NO
RESPIRATORY
Cough
Shortness of breath
Coughing up blood
Frequent hiccoughs
Chest pain upon breathing
Wheezing
CARDIAC
Irregular heartbeats
Chest pain
Swelling
Shortness of breath with lying down
GASTROINTESTINAL
NO
Abnormal Bowel habits
NO
Diarrhea
NO
Bloody vomit
NO
Hemorrhoids
NO
Nausea
NO
Feeling “full” shortly after eating
NO
VASCULAR
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
Poor Circulation
Leg cramps
Varicose veins
Clots in veins
Getting up at night to urinate
Renal stone disease
Impaired sexual function
Urgency
Urine color change
Vaginal discharge/bleeding
Vaginal spotting
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
MALE ONLY
Burning with urination
Frequent urination
Blood in urine
Impaired sexual function
Incontinence
Waking up at night to urinate
Renal stone disease
Scrotal swelling
Urgency
Urine color change
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
MUSCULOSKELETAL
Arthritis
Bone pain
Joint Pain
Muscle weakness
Range of motion
Limited range of motion (where?)
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
HEMATOLOGICAL/LYMPHATIC
Easy Bruising
YES
Swollen Lymph nodes
YES
NO
NO
NEUROLOGIC
Disorientation/confusion
Dizziness
Difficulty walking
Headaches
Inability to sleep at night
Memory Loss
Nerve Pain
Loss of muscle function
Seizure
Difficulty performing daily activities
Stroke
ENDOCRINE
Hot/cold intolerance
Excessive sweating
Excessive thirst
Excessive hunger
YES
YES
YES
YES
NO
NO
NO
NO
Mental Health
Anxiety
Hallucinations
Depression
Mood swings
YES
YES
YES
YES
I attest that all of the information in this document is true and correct to the best of my knowledge
and understand my physician will base his opinions and judgments on the same.
_____________________________________________
___________________
Patient Signature
Date
NO
NO
NO
NO