Welcome to Ventura County Radiation Oncology Medical Group (VCROMG).

Transcription

1 Page 1 PERSONAL HISTORY AND PATIENT QUESTIONNAIRE New Patient Returning Patient AGE: DATE: Welcome to Ventura County Radiation Oncology Medical Group (VCROMG). Please provide us with a list of your physician team followed by a few questions specific to our office. PHYSICIAN TEAM Physician Name: Phone : Primary Care: Medical Oncologist: Surgeon: Other: Other: Other: RADIATION THERAPY HISTORY: Have you had prior radiation therapy? Yes If yes, what part of the body was treated Location of Facility/Treating Physician Has a family member or friend ever been treated by Dr. O Connor or Dr. Montes? Yes If yes, please list their name(s): CARDIAC DEVICE: Do you have a pacemaker or ICD (defibrillator)? Yes If yes, date last checked Please bring your cardiac device card with you to your appointment. ADVANCE DIRECTIVE: Do you have an Advance Directive? Durable Power of Attorney Living Will or DNR Name of person assigned Phone number Oxnard Center 1700 rth Rose Ave, Ste. 120, Oxnard Ca Phone: (805) Fax: (805)

2 Page 2 CURRENT MEDICATIONS AND ALLERGIES: If you are unable to fill this section out PLEASE bring your medications with you to your appointment! See Attached List Medication Name: # of milligrams: How many times a day? Are you currently taking Multi-Vitamins or Anti-Oxidants?: Please list them: PREVIOUS CHEMOTHERAPY? Yes PRESENT OR PLANNED TREATMENTS IN FUTURE? Yes If YES: Name of Drug: Date of Last Treatment: DRUG, FOOD OR LATEX ALLERGY: ne List what you are allergic to: Type of reaction: PHARMACY: ADDRESS: PH# CONSENT FOR E-PRESCRIBING & OBTAINING MEDICATION HISTORY I understand that as a part of my electronic health record, VCROMG will transmit my prescriptions electronically as permitted, to the pharmacy that I designate as my primary pharmacy provider. Additionally, VCROMG will obtain the history of my prescriptions from pharmacy benefit managers and I understand that those prescriptions will become a part of my electronic health record. By signing below I hereby give consent to the above actions. SIGNATURE DATE Oxnard Center 1700 rth Rose Ave, Ste. 120, Oxnard Ca Phone: (805) Fax: (805)

3 Page 3 If you are a returning patient and your Medical/Family/Social History has not changed since your last visit please check here and skip to page 5 (last page). MEDICAL HISTORY: Please mark any you have now or have had in the past. previous medical or surgical history Anemia Asthma Atrial Fibrillation Bleeding disorder Blood clots Cancer (Type) Chronic lung disease (COPD) Cirrhosis of liver Colon polyps Congestive Heart Failure Connective tissue disease (e.g. scleroderma) Crohn s disease Diabetes Diverticulitis Emphysema Enlarged prostate Frequent Urinary Tract infections Gallstones Glaucoma/cataracts Hearing loss (R/L) Heart attack-mi Heartburn/Reflux Heart murmur Hepatitis A/B/C High blood pressure High Cholesterol/Triglycerides HIV/AIDS Irregular Heart Beat Irritable Bowel Syndrome Kidney stones Kidney Disease/Failure Autoimmune Migraines Neuropathy MRSA Osteoarthritis Osteoporosis Pancreatitis Paralysis (area) Parkinson s Disease Peripheral Vascular Disease Pneumonia/ Bronchitis Reynaud s Syndrome Rheumatic fever Rheumatoid Arthritis Seizures Sleep Apnea Stomach ulcer Stroke TB (Tuberculosis) Thyroid Disease TMJ Ulcerative colitis Other Illnesses t Listed: Have you had a... Colonoscopy? Yes Mammogram? Yes Bone Scan? SURGICAL HISTORY: Type: Yes Complications: Oxnard Center 1700 rth Rose Ave, Ste. 120, Oxnard Ca Phone: (805) Fax: (805)

4 Page 4 GYNECOLOGICAL-FOR WOMEN ONLY: Age at first menstruation Frequency of cycle (every so many days) Date of last menses Possibility you are or may be pregnant? Yes Age at first pregnancy Number of pregnancies Number of live births Breast fed? Yes Age at start of menopause Have you used estrogen supplementation? Yes FAMILY HISTORY OF CANCER: Yes If yes: Family Member Cancer Type If alive, Age If deceased, Age and cause SOCIAL HISTORY: Occupation: Retired Yes Family/Friend support person: Do you live alone, with spouse or with another family member? Please specify: Do you or have you ever smoked cigarettes? Yes Other tobacco products? Yes Current everyday smoker? How much? Former smoker? How much? Date quit Do you drink alcohol? Yes How Much? Do you have a history of illicit drug use? Yes If yes, approximately when: Oxnard Center 1700 rth Rose Ave, Ste. 120, Oxnard Ca Phone: (805) Fax: (805)

5 Page 5 REVIEW REVIEWOF OFSYSTEMS: SYSTEMS: Do you currently have? (If yes, check appropriate boxes) Check here here if if no no current current symptoms symptoms Check Height Weight Height Weight GASTROINTESTINAL EYES Double Vision EYES/OSOS Eye Pain Double Vision Eye Pain ENMT Decrease Hearing ENMT Aids Hearing Ear Pain Decreased Hearing se Bleeds Hearing Aids Dry EarMouth Pain se Bleeds Hoarseness DryUlcers Mouth Oral Hoarseness Sore Throat Oral Ulcers Sore Throat CARDIOVASCULAR Chest Pain CARDIOVASCULAR Leg Pains with Walking Chest Pain Leg Pains with Walking Palpitations Leg Swelling Shortness of Breath Palpitations Shortness of Breath Leg Swelling RESPIRATORY Decreased Exercise Tolerance RESPIRATORY Difficulty Breathing Decreased Coughing UpExercise Blood Tolerance Sputum Production Coughing Up Blood Sputum Production IMMUNIZATION HISTORY: NEUROLOGIC Abdominal Pain Dizziness/Vertigo Diarrhea Abdominal Pain Numbness/Tingling GASTROINTESTINAL Constipation Nausea Constipation Diarrhea Vomiting NauseaSwallowing Trouble Vomiting Trouble Swallowing Rectal Bleeding GENITOURINARY Rectal Bleeding Painful Urination GENITOURINARY Increase Frequency Lack of Bladder Control Painful Urination Blood in Urine Increased Frequency Lack ofdischarge Bladder Conttrol Vaginal Vaginal Discharge Menstrual Irregularities Menstrual Irregularities Blood in Urine MUSCULOSKELETAL Muscle Weakness MUSCULOSKELETAL Muscle Aches/Pains Joint Pain INTEGUMENTARY Muscle Weakness (SKIN/BREAST) NEUROLOGIC Headaches Loss of Bowel Control Dizziness/Vertigo PSYCHIATRIC Headaches Anxiety Numbness/Tingling Depression PSYCHIATRIC ENDOCRINE Anxiety Increased Sweating Depression Hair Changes ENDOCRINE HEMATOLOGY Increased Sweating Easy Bruising Increased Urination Hair Changes Enlarged Lymph des Prolonged Bleeding Anemia HEMATOLOGY CONSTITIONAL Easy Bruising Fatigue Enlarged Lymph des Weight Loss Bleeding > 10 pounds Prolonged Poor Appetite Anemia Weight Gain > 10 pounds Muscle Aches/Pains New skin lesion Rash Diet Restrictions Breast Pain Location INTEGUMENTARY Breast Mass (SKIN/BREAST) CONSTITUTIONAL Pain Scale 0-10 Fatigue Weight Gain> 10 pounds Rash Weight Loss> 10 pounds Breast Mass Poor Appetite Breast Pain Diet Restrictions Have you received Pneumonia vaccine? Nipple Discharge Pain Scale 0-10 Skin ChangesYes Date Nipple Discharge New lesions Have you received a Influenza (flu) vaccine? Yes Date Personal reasons Medical reasons Personal reasons Medical reasons Print Name Patient Signature Date Print Name: Patient Signature:

6 VENTURA COUNTY RADIATION ONCOLOGY MEDICAL GROUP, INC. ASSIGNMENT OF BENEFITS this carefully prior to signing below. Ventura County Radiation Oncology Medical Group, Inc. (VCROMG) will make every effort to obtain authorization for the requested services from your insurance company/carrier. We will also bill your medical carrier directly for the services that we provide. portion of the amount that VCROMG bills to them. For example, patients are typically responsible for paying deductibles, co-insurance, and co-payments. Our Financial Counselors will be happy to answer any questions or concerns you may have regarding your payments as easy as possible on you and your family. By signing this document, you acknowledge and authorize the following: I authorize the release of medical information to my insurance company and to any other physicians participating in my medical care. 3. I acknowledge responsibility for the amounts not paid by my insurance company. 4. I agree to meet with the VCROMG s Financial Counselor as necessary to arrange a payment plan for scheduled, current or outstanding balances. Print Patient Name Date Signed: Patient Signature INSURANCE ELIGIBILITY CERTIFICATION I understand that it is my responsibility to provide VCROMG with accurate information regarding my Medical Insurance Coverage. Should there be any change in my coverage I agree that I am responsible to notify resulting unpaid claims. Print Patient Name Patient Signature Oxnard Center 1700 rth Rose Ave, Ste. 120, Oxnard Ca Phone: (805) Fax: (805)

7 VENTURA COUNTY RADIATION ONCOLOGY MEDICAL GROUP, INC. PATIENT REGISTRATION Name: Age: Gender: M / F Address: City: State: Zip Code: Primary Phone (home/cell): Other (home/cell): Do not have Decline Preferred Language: Marital Status: S M W D Retired/Employed At: Work#: Emergency Contact: Relationship: PH#: INSURANCE INFORMATION Primary Insurance: ID#: Subscriber Name: Group#: Secondary Insurance: ID#: Subscriber Name: Group#: Social Security Number: For Tricare/Triwest Patients: Rank: Military Branch: This information is required for Cancer Registry and Research Purposes Race: Religion: Ethnicity: Hispanic? Y / N Place of Birth: Patient Signature: Legal Guardian or Authorized Person: Relationship: Account #: Primary DX: ICD-9: Referring MD: MD: TOC / HZM Metastatic DX: ICD-9: Phone: Skilled Nursing Facility: Insurance Verified Date/Initials: Oxnard Center 1700 rth Rose Ave, Ste. 120, Oxnard Ca Phone: (805) Fax: (805)