DATE OF BIRTH: MELANOMA INTAKE
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- Monica Allen
- 5 years ago
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1 MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other If "other", briefly describe the reason for your visit: (Chose from the "Physician Diagnosed" or "Patient Diagnosed" options below.) *PHYSICIAN DIAGNOSED* Routine Exam Symptom Directed Exam Abnormal Test or X-Ray Have you noticed any of the following related to the lesion: Bleeding Change in Shape (Edges) Itching *PATIENT DIAGNOSED* New or Changing Lesion New or Cutaneous Symptom Lymph Node Mass Change in Color Change in Size Increased Pain Describe any other changes than those listed above: What is the date that you first discover this lesion? What changes, if any, have you noticed since discovery, and when did they occur? Date of biopsy? Result: THERAPIES PERFORMED TO DATE Was a wide local excision performed? Yes No If yes, who performed the excision and what was the approximate date? Was a lymph node dissection performed? Yes No If yes, who performed the excision and what was the approximate date? Have you undergone chemotherapy or radiation treatment? Neither Chemotherapy Radiation If yes, which physician supervised and performed the procedure? What was the approximate date?
2 REVIEW OF SYSTEMS Please indicate whether you are experiencing or suffer from any of the following: NOTE: If NONE of the below apply and there are no conditions to add in the "Additional Information" area, check this box to indicate you are NOT experiencing or suffering from any medical conditions. GENERAL Y N SKIN Y N EYES Y N Fatigue Change in Mole Appearance Blindness Fever Hair Loss Cataracts Sweats Itching Glaucoma Generalized Weakness Rash Vision Changes GENITOURINARY Y N MUSCULOSKELETAL Y N PSYCHIATRIC Y N Painful Urination Arthritis Anxiety Blood in Urine Artificial Joints Bipolar Disorder Kidney Failure/Dialysis Fibromyalgia Depression Kidney Stones Joint Pain / Stiffness Suicidal Thoughts Incontinence Muscle Cramping Schizophrenia Urinary Tract Infections Swelling of Joints HEART Y N NEUROLOGICAL Y N GASTROINTESTINAL Y N Arrhythmia Episodes of Vision Loss Abdominal Pain Atrial Fibrillation Headaches Black, Tarry Stools Chest Pain Memory Loss Blood in Stools Congestive Heart Failure Migraines Constipation Fainting Episodes Multiple Sclerosis Diarrhea Heart Attack Numbness/Tingling Heartburn Heart Murmur Paralysis Hemorrhoids Hypertension Parkinson's Disease Irritable Bowel Syndrome Pacemaker (Please bring card) Seizure Disorder Nausea or Vomiting Palpitations Slurred Speech Rectal Bleeding Stents Stroke Hiatal Hernia Tremors
3 EAR/NOSE/THROAT Y N LUNGS Y N HEMATOLOGICAL Y N Dizziness Chest Pain Anemia Hoarseness Cough Blood Transfusions Nosebleeds Coughing with Blood Leukemia Ringing In Ears History of Lung Nodules Lymphadenopathy Runny Nose History of Tuberculosis Prone to Bleeding Sinus Infection Shortness of Breath Prone to Bruising Sore Throat Sleep Apnea Sickle Cell Disease Wheezing Thrombosis (Blood Clots) * ARE YOU CURRENTLY PREGNANT? YES NO NOT APPLICABLE FAMILY HISTORY Please indicate if anyone in your family has been diagnosed with any of the following: CONDITION / DISORDER NONE MOTHER FATHER SIBLING CHILD GRANDPARENT Bleeding Disorder Cancer (Non-melanoma) Diabetes (Type I) Diabetes (Type II) Epilepsy Heart Disease Hypertension Glaucoma Kidney Disease Melanoma Stroke Thyroid Disease Thrombosis (Blood Clots) Additional Information - Please elaborate on any pertinent family medical history:
4 SOCIAL HISTORY What is your marital status? Single Married Divorced Separated Widow / Widower Domestic Relationship What is your employment status? Employed full time Employed part time Currently unemployed Retired Working at home as MOM Working at home as DAD A lucky-duck lottery winner! What is your primary occupation? Do you use tobacco products? YES NO Describe your tobacco use, please. (What type of tobacco do you use, and how often.) What is your tobacco status? I have never smoked. I am a former smoker. I am a light tobacco smoker. I am a current every day smoker I am a current some day smoker. I am a heavy tobacco smoker. Do you drink alcoholic beverages? YES NO My alcohol usage is: I drink on special occasions only. On average, I have less than five alcoholic beverages per week. On average, I have between five and ten alcoholic beverages per week. On average, I have in excess of ten alcoholic beverages per week. I drink alcoholic beverages every day. I believe I have an alcoholic addiction..
5 PAST MEDICAL HISTORY Please indicate whether the following chronic conditions apply. A Chronic condition is a s persistent or otherwise long-lasting medical condition. NOTE: If NONE of the below apply and there are no conditions to add in the "Other" or "Additional Information" areas, check this box to indicate there are no ongoing medical conditions. CHRONIC CONDITION Y N CHRONIC CONDITION Y N CHRONIC CONDITION Y N Allergies Chronic Bronchitis Hypertension Alzheimer's Disease Cirrhosis Kidney Disease Anemia Clotting Disorder (Thrombosis) Lupus Anxiety COPD (Lung Disease) Lymphoma Arrhythmia (Atrial fibrillation, etc.) Depression Meningitis Arthritis Diabetes Mellitus Type I Myocardial Infraction Asthma Diabetes Mellitus Type II Nerve/Muscle Damage Blood Transfusion Emphysema Osteoporosis Breast Issues GERD (Heartburn) Polycythemia Vera Cancer (Specify below) Glaucoma Polymyalgia Rheumatica Cataracts Heart Murmur Rheumatoid Arthritis Congestive Heart Failure HIV / AIDS OTHER (Specify below): ADDITIONAL INFORMATION - Please provide relevant specific information relating to your past medical history: Have you had either of the following vaccinations: Influenza (Flu) YES NO Approximate Date Pneumococcal (Pneumonia) YES NO Approximate Date SURGERY AND MEDICAL PROCEDURE HISTORY DATE NAME OF PROCEDURE / SURGERY UNDERLYING CONDITION
6 PHARMACY INFORMATION What is the name of the pharmacy you would like us to utilize for prescriptions? What is the address of the pharmacy you listed? What is the pharmacy telephone number? MEDICATIONS Please list all medications you take, including over-the-counter (OTC) medications and vitamins. Include specific doses and when taken. If you don't know, please call your pharmacist to confirm. NAME DOSAGE FREQUENCY TAKEN ALLERGIES Please list any medical related allergies below (prescriptions, latex, etc.)
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
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Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
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Athens Rheumatology Clinic, LLC Sana Makhdumi, MD
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This form contains questions specific to the Department of Surgery. If you are new to Baylor College of Medicine and have not been seen in any of our offices, please be sure to complete our New Patient