HEALTH HISTORY QUESTIONNAIRE. Family Risk Assessment Program
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1 HEALTH HISTORY QUESTIONNAIRE Family Risk Assessment Program Name DOB Current Age Address Home Phone Cell Phone Business Phone Best time to contact you Day Evening Address ( will only be used for this program communication, and not shared without your request and/or consent) Female Male City, State, Country of Birth Physician (s) (If one of the above is your PRIMARY physician, please indicate by circling name) Signature Date This form will be reviewed with you at your visit and used to help us identify your individual cancer risks and promote discussion about risk reduction strategies.
2 About Your Family: (We request this information because some cancer syndromes and cancer risks affect certain ethnic groups more than others.) Mother s Family Father s Family Countries of origin (you may list more than one Religion (you may list more than one) Race, ethnicity (you may list more than one) (Ex s: Caucasian, African, Hispanic, Asian, Caribbean, Middle Eastern, Native American. Your highest level of education completed: Elementary school High School Associate degree Bachelor Degree Graduate degree Marital Status: (ex. Single, married, divorced, separated, civil union, never married, widowed, etc. ) Increased risk for some cancers has been associated with sexual history and lifestyle, such as (but not limited to) multiple sexual partners, same-sex relationships, oral and anal intercourse. Sharing your sexual identity and experiences with us will allow us to better complete your cancer risk assessment. This information remains confidential. You may choose to NOT respond if you wish. Please indicate which of the following best describes you (you may indicate more than one): Heterosexual Gay/Lesbian Bisexual Transgender Questioning Celibate More than 1 partner Do not wish to respond Past Present
3 Primary Occupations, past and present: (to help us assess occupational risks) Have You Ever Had (Or Been Exposed To) Any Of The Following Potential Risk Factors? (at home or work) YES NO DON T KNOW PLEASE LEAVE THIS COLUMN BLANK Asbestos Second Hand Smoke Chemicals, Solvents, Pesticides, Petroleum Products Radiation (even as an infant) Sunburns Hormone Replacement (Male Or Female) DES (a hormonal medication) (Did your mother take it when pregnant with you?) Unusual skin moles Human Papilloma Virus (HPV) Hepatitis Epstein-Barr Virus H. Pylori Infection (Stomach) Barrett s Esophagus? Have you ever had intestinal polyps? Do you have Ulcerative Colitis or Crohns Disease? Have you ever been exposed to an environmental agent such as Agent Orange (Vietnam), Radiation (Chernobyl), or Inhaled Particulate Matter (World Trade Center)? Have you ever used Tamoxifen or Raloxifene ( Evista )? Did you serve in the military?
4 About Your Health (Current And Past): Your current height Your current weight Allergies Your weight at age 18, 30, 40 Your maximum non-pregnant wt (age) Have you been diagnosed with cancer within the past 12 months? Have you been diagnosed with cancer previously (more than one year ago)? Are you receiving long term treatment for a chronic condition such as heart disease, diabetes, kidney disease, high blood pressure, osteopenia, respiratory problems, or another condition? Have you ever had surgery? If yes, please list all. Have you ever had a breast biopsy? If yes, please list dates and results. Have you ever had a biopsy of an area other than the breast? If yes, please specify type, date(s), and results. YES NO Please provide brief detail PLEASE LEAVE THIS COLUMN BLANK Please list any current medication you take (include over the counter (non-prescription) medications and herbal or dietary supplements). Please include dosage and frequency of use. Please describe your diet (ex., regular, low fat, vegetarian, high fiber, etc.). How many servings of the following do you eat daily? Fruit Vegetables Red meat
5 Please describe your current exercise pattern, habits or practices, (include length and how many times a week): This Section Helps Us Identify Cancer Risk Factors: Please describe your personal tobacco use (past and present), including amounts smoked, frequency, and type of tobacco (cigar, pipe, cigarettes, smokeless). (for instance I smoked a pack per day from age 18-28, then for the next 10 years it was ½ pack a day for 2 years before I quit completely, always cigarettes, never a pipe or cigars ). Please describe your personal alcohol use (past and present) including amount and type of alcohol (wine, beer, mixed drinks), and frequency of use. (For instance, I was a binge drinker in my college years, but by age 24 I only drank socially. However, I had a period from age when I drank 2-3 beers nightly. At 46 I stopped except for an occasional glass of wine or mixed drink when we are out. ) Please describe your past exposure to X-rays. (If none other than routine dental X-rays, please state routine dental.) Is there anything else about your personal medical history or exposure history that causes you to perceive your risk for cancer as higher than the average person? FOR WOMEN ONLY: Age you were when your periods began Age at menopause (if applicable) Are (were) your periods regular? How many days apart Have you ever had a full-term pregnancy? Yes No If yes, how old were you at the time or your first full-term delivery? Did you breast feed for a total of more than 6 months? Yes No N/A Have you had a tubal ligation? Yes No If yes, when
6 Have you had gynecologic surgery? Yes No If yes, what kind? Have you ever had fertility treatment? Yes No Cause of infertility? If yes, please describe Have you ever used hormonal contraceptives, such as the pill, patch, shot or implant? Yes No If yes, please describe (products used, total length of time used, etc.) Have you used hormone replacement therapy? Yes No Reason If yes, please describe (products used, total length of time used, etc.) We will review more about pregnancies, birth control and hormone therapy at the time of your visit, but please tell us about all pregnancies at this time. Date of delivery Your age at delivery Out come (birth, miscarriage, therapeutic termination. stillborn Length of pregnancy, Baby weight Type of delivery (vaginal, ceasarean) Breast feed (yes/no) If yes, how long Problem breastfeeding? (describe) Medication to stop milk production? (name, pill or injection) 1st pregnancy 2 nd pregnancy 3 rd pregnancy 4 th pregnancy 5 th pregnancy 6 th pregnancy Have you had additional pregnancies? Yes No (If you had more pregnancies we will detail those at your visit)
7 FOR MEN ONLY: Have you ever had any fertility problems? Yes No If yes, please describe Have you had a vasectomy? Yes No Have you ever been diagnosed with or treated for gynecomastia (enlargement of male breast tissue)? Yes No Have you ever received hormone treatment? Yes No If yes, please describe FOR MEN AND WOMEN - CANCER SCREENING HISTORY: We will review your cancer screening and prevention history with you during your visit. Please help us prepare by answering the following to the best of your ability. IF YOU HAVE NEVER HAD A SPECIFIC EXAM, PLEASE INDICATE WITH NEVER. FOR BOTH MEN and WOMEN Skin self exam Skin exam by a physician or other health care provider Month/year of last exam How often do you have this exam? Has this exam ever been abnormal? (yes) (no) Please leave this column blank Oral screening (usually through routine dental care) Colonoscopy Sigmoidoscopy Barium enema Testing for blood in stool
8 FOR WOMEN ONLY - CANCER SCREENING HISTORY: FOR WOMEN ONLY Month/year of last exam How often do you have this exam? Has this exam ever been abnormal? (yes) (no) Please leave this column blank Breast self exam Breast exam by physician or other health care provider Mammogram Ultrasound of the breast MRI of the breast Pap smear Pelvic exam (with or without pap smear) Ca 125 (blood test) Transvaginal ultrasound FOR MEN ONLY - CANCER SCREENING HISTORY: FOR MEN ONLY Prostate exam (digital rectal exam) PSA (prostate specific antigen, a blood test) Testicular self exam Month/year of last exam How often do you have this exam? Has this exam ever been abnormal? (yes) (no) Please leave this column blank FOR MEN AND WOMEN: Hunterdon Regional Cancer Center contributes to research about cancer genetics, risk factors for cancer, and cancer prevention. These studies do not require taking investigational medications. Many of these studies require only completing a questionnaire; some also require submission of a blood sample. Would you be interested in discussing (without obligation) participation in this type of cancer research? Yes No
9 Family History of Cancer Has anyone in your family ever been diagnosed with cancer? Yes No If yes, please describe the cancer history below. Please specify if a relative such as a grandparent, cousin, or aunt/uncle is on the maternal (mother s) side or paternal (father s) side. If you don t know the age at which a relative s cancer was diagnosed but know an approximate age ( 40 s, 70 s ), please provide that Name / Relationship to you Type of cancer Age at diagnosis Please circle Name/ Relationship to you Type of cancer Age at diagnosis Please circle Name/ Relationship to you Type of cancer Age at diagnosis Please circle Name/Relationship to you Type of cancer Age at diagnosis Please circle Name/Relationship to you Type of cancer Age at diagnosis Please circle Name/Relationship to you Type of cancer Age at diagnosis Please circle Name/Relationship to you Type of cancer Age at diagnosis Please circle Name/ Relationship to you Type of cancer Age at diagnosis Please circle Name/ Relationship to you Type of cancer Age at diagnosis Please circle Name/Relationship to you Type of cancer Age at diagnosis Please circle If you need more space, please use another sheet or the back of this sheet. 9/2013
10 INFORMATION TO SUPPORT RESEARCH AT CITY OF HOPE (COH), DUARTE, CALIFORNIA We encourage you to complete this page as well, though the information is not essential to your risk assessment here at Hunterdon Regional Cancer Center. If you choose to help us support the research conducted at COH, this information is also submitted to the researchers. 1. On a scale of 0% (no risk to 100% (certain to occur what do you think is your risk of developing cancer of the* Breast Colon Ovary Prostate Uterus Other (name type) *If you already had any of these cancers, please give an estimate of what you thought your risk was before diagnosis. 2. What do you think influences(d) your risk for cancer? (select all that apply) Environmental exposures Genetics Eating Habits God s will Family History Stress Fate Other, specify 3. If you had a cancer that could be genetically related do you think there is a responsibility to inform your relatives? Yes No Unsure If yes, who should inform them? You Your healthcare provider Other If yes, what method should be used? Mail in person Phone 4. (For women) How old were you when you had your first mammogram. What was the reason for your first mammogram? 5. (For women) Have you ever participated in breast cancer prevention clinical research such as the BCPT study or the STAR study)? Yes No If yes, which study? 6.. Have you ever taken any medication to prevent cancer? Yes No 7.. Do you have breast implants? Yes No If yes, for reconstruction or augmentation? 8.. Have you had cosmetic breast reduction? Yes No For individuals who have had breast cancer: 9. How was your cancer identified? (for example felt it myself, my doctor felt it, routine mammogram) 10. If you have had a second breast cancer, how was your cancer identified? (for example felt it myself, my doctor felt it, routine mammogram)
11 Please list a friend or relative not living with you who will always know how to reach you: Name: Relationship: Address: Telephone: H ( ) Work: ( )
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Clinic Adult Patient Demographics Patient s Name: Previous or Nickname: Sex: Male Female Social Security Number - - Date of Birth: Mailing Address: City State Zip Code Home Phone #: ( ) - May we leave
Wheaton Franciscan Healthcare
Today s Date Wheaton Franciscan Healthcare PATIENT AND FAMILY MEDICAL HISTORY Patient s Name: Marital Status: r Married r Single r Divorced r Widowed r Other Date of Birth: Gender: r Male r Female Religion:
16 East 40 th St, 2 nd Fl, New York, NY Ph fax
Page 1 of 9 16 East 40 th St, 2 nd Fl, New York, NY 10016 Ph 212-679-2289 fax 212-679-2288 Please complete the following: Fertility Evaluation Name: Date of birth: Age: Partner s Name: Date of birth: Age:
PRE-VISIT QUESTIONNAIRE FOR NEW PATIENTS
UF Health Senior Care PO Box 100383 Gainesville, FL 32608 352-265-0615 Fax 352-294-5803 PRE-VISIT QUESTIONNAIRE FOR NEW PATIENTS Please complete this questionnaire at home and bring it with you to the
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
Preventive Care Risk Assessment
Preventive Care Risk Assessment Name: DOB Date Lung Cancer (please check all that apply) You currently smoke cigarettes, cigars, or pipes. You have a history of second-hand smoke exposure. You have been
Recommended Preventive Care Snapshot
Preventive Care Recommendations For quick reference, this snapshot provides a general list of preventive care recommendations that you and your family members may need to consider. It also describes what
Premier Internal Medicine of Alpharetta, PC
Patient Information Date / / First Name Middle Initial Last Name Date of Birth / / Social Security # Gender Male Female Marital Status Single Married Separated Divorced Widowed Address Apt # City State
Englewood Orthopedic Associates 401 South Van Brunt Street Englewood, NJ Tel: Fax: Jessica Fleischer, MD
Englewood Orthopedic Associates 401 South Van Brunt Street Englewood, NJ 07631 Tel: 201.569.2770 Fax: 201.569.1774 Jessica Fleischer, MD Date: Name: Address: City: State: Zip Code: Age: DOB: / / Gender:
Last Name First Name MI SS# DOB. Address. City State Zip. Best Phone# (home/ work/ cell) Alternate # (home/ work/ cell)
39 th and Market Street, Penn Presbyterian Medical Center, MOB 340 Philadelphia, PA 19104 215-662-9775 823 South 9 th Street, 1 st Floor Philadelphia, PA 19147 267-239-2725 Last Name First Name MI SS#
Patient Intake Form. Male Female Employment Status Employer Employer Address Employed
Thank you for choosing Community Hospital-Fairfax Family Medicine Clinics. We are delighted to provide your care. If you are a patient of the Rock Port, Tarkio or Fairfax Clinics, please complete this
Please complete and return to the office prior to your appointment.
Please complete and return to the office prior to your appointment. Name: Last:, Today s Date: First: MI: Nickname: Date of Birth: Age: Sex: M F SSN: Parent/Legal Guardian (if the patient is a minor):