Name. Date of Birth. Primary Care Doctor? Who is the Doctor that referred you to us? Name of person completing this form?
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- Anastasia Margaret Russell
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1 Orthopaedic Surgical Oncology of Arizona Dr Bruce A Mallin Dr Matthew J Seidel PATIENT HISTORY FORM To help us better understand your risk factors for cancer, please complete this medical history. Please circle the appropiate response to the questions below. Date Age Date of Birth Primary Care Doctor? Who is the Doctor that referred you to us? Name of person completing this form? What primary language do you speak? Current Medical History: What is the problem you are being seen for today and which side? Do you have pain? YES or NO or SOMETIMES If you have pain, rate your pain on a scale of 1-10, ( 1 is very little to no pain and 10 is extreme pain) Where is the pain located? (ie: L arm, R leg, back, pelvis) Describe the pain? (ie: dull, throbbing, sharp, stabbing) What makes your pain better? What makes your pain worse? Do you have a lump, bump, mass, lesion, cyst, tumor? YES or NO NOT SURE When did you first notice this bum, lump? Do you notice it changing in size? YES or NO NOT SURE Does it cause you pain? YES or NO NOT SURE Did you have an injury or trauma to this area? YES or NO NOT SURE When did this problem start? Have you had any Treatment for this problem in the past? Name of any previous treating providers for this problem?
2 Orthopaedic Surgical Oncology of Arizona Dr Bruce A Mallin Dr Matthew J Seidel Have you ever been diagnosed with any type of cancer in the past? Yes or No What type of cancer were you diagnosed with in the past? Have you had prior Radiation treatment? Yes or No Year you received Radiation treatment? Have you had Prior Chemapy treatments? Yes or No Year you received Chemapy treatments? Past Medical History: Please check all previous illnesses or conditions below. Cancer Lung problems Diabetes or sugan in urine Heart problems Liver problems Thyroid problems High blood pressure Kidney/urine problems Frequent infections Circulation problems Bleeding problems HIV / AIDS Stroke Psychological/Psychiatric Osteopenia/Osteoporosis Seizure Other Please provide more information for any of the conditions or illnesses you checked above (if you checked any box above, please list the exact problem) Please list any surgeries and the date of the surgery that you have had in the past. (1) (5) (2) (6) (3) (7) (4) (8) Please list any Hospitalizations,include the reason and date of Hospitalization (not related to the above mentioned surgeries)
3 Orthopaedic Surgical Oncology of Arizona Family History Are you Adopted? Yes or No Are you a Twin? Yes or No What type of twin? Identical Fraternal Not Sure Are you Married? Yes or No Not including yourself, How many family members do you have? (include those living and those no longer living) Brs Sisters Sons Daughters Are there any diseases or medical conditons (besides cancer) which run in your family? (diabetes,stroke, heart disease) Problem Family Member (ie: m, father, sisters, brs). Complete the table below for each of your Blood-Related relatives who have had cancer. If the family member is on your Ms side mark an "M" in the box if the relative is on your fathers side mark an "F" in the box. List how the Relative is related to you under relationship (aunt, uncle, grandparent, cousin) Relationship Side of Family Still Living Age Died Kind of Cancer/Location M/F Y/N Work History If you are a student, what grade are you currently in? What job have you held for the longest period of time? (including student or homemaker)
4 What is your current occupation? Are you currently able to work? Yes or No Not Applicable Orthopaedic Surgical Oncology of Arizona Tobacco History: Have you ever smoked cigarretes in your lifetime? Yes, currently I did but I quit Almost Never No Never Have How old were you when you first started smoking cigarettes? On average, how many cigarettes do you smoke a day? If you quit, when did you quit? DO YOU Yes No Quit Year Quit Amount Used Years Used Chew tobacco Snuff or Dip Smoke a Pipe Smoke Cigars Alcohol History: Do you drink alcoholic beverages? Yes, currently I did but I quit Almost Never No Never Have On the average, how many drinks do you have a week? If you did drink but have quit, when did you quit? Illegal Drugs: Have you ever used ANY recreational (street) drugs? Yes, currently I did but I quit Almost Never No Never Have What drug?
5 Orthopaedic Surgical Oncology of Arizona Current Medication (include prescription, over - the - counter and herbals) Name of Medication Dose How often taken Reason for taking Length of time taken Do you have any allergies or reactions to any MEDICATIONS? (List the name of the medication and the reaction is causes if you answer YES) Yes or No Medication Reaction Do you have any allergies OTHER than to MEDICATIONS? Yes or No Allergy Reaction
6 Orthopaedic Surgical Oncology of Arizona Review of Systems: Please check all problems that you are having now. If none apply to you, please check the box None. General: Gastrointestinal: Skin: change in sleep habits yellow skin or eyes open sore chills nausea/vomiting change in moles fatigue problems swallowing abnormal color fever cramping/stomach pain rashes night sweats indigestion weight gain reflux NONE weight loss diarrhea Other constipation Neurological: NONE black stool memory changes blood in stool numbness/tingling Head & Neck: dizziness/fainting hoarseness NONE weakness nosebleeds blurred vision sore throat Genitourinary/Breast: headache sores in mouth or throat burning ringing in ears frequency seizures NONE blood in urine speech changes dribbling Cardiovascular: unable to control bladder NONE chest pain problems with passing urine fast heart beat enlarged prostate Psychological: urinary incontinence worried/anxious NONE unusual bleeding/discharge sad/depressed breast changes Respiratory: breast lumps NONE wheezing nipple discharge cough birth control Hematologic/Lymphatic: short of breath abnormal bleeding bloody phlegm/sputum NONE lymphedema easy bruising NONE Musculoskeletal: ( than reason for visit) history of DVT/PE joint swelling prior transfusion Endocrine: join/back pain swelling in groin/armpit cold intolerance stiffness hot flashes trauma NONE NONE falls NONE
New Patient Information Form
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Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
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Marcelo Garzon HOM.DSHomMed.Bsc. (Please be certain that all in take forms are completed and returned on time)
Marcelo Garzon HOM.DSHomMed.Bsc. www.sagehomeopathy.ca (Please be certain that all in take forms are completed and returned on time) NAME: Personal Health History DATE: OHIP # D.O.B : AGE: PHONE: MAY WE
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By