HEMATOLOGY / ONCOLOGY PATIENT HEALTH HISTORY

Transcription

1 ALVIN & LOIS LAPIDUS CANCER INSTITUTE HEMATOLOGY / ONCOLOGY PATIENT HEALTH HISTORY Name: Date of Birth: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Social Security Number: Your Primary Care Provider: Address: Phone Number: What Other doctors do you see? (Name of Doctor & Purpose for seeing doctor) Employer: Occupation: Emergency Contact Name, Number and Relationship: Responsible Party (if different from patient) Name, Number and Address: Primary Health Insurance: Policy Number: Group Number: Secondary Health Insurance: Policy Number: Group Number: PLEASE BRING ALL MEDICATIONS TO YOUR SCHEDULED APPOINTMENT Name of Medication Dosage How Often Taken Reason For Medication How Many Pills

2 Please list any allergies you may have to food, latex, medications or the environment. Please also include your reaction: Have you ever had a reaction to anesthesia? YES NO If yes, please specify: Have you ever had a reaction to I.V. Contrast or shellfish? YES NO If yes, please describe: Who referred you to our facility and for what reason?

3 If you have ever had any of the following problems, check all that apply: Anemia Bleeding Tendency Blood Transfusions Migraine Headaches Glaucoma Asthma Tuberculosis Bronchitis Back Trouble Hernia Bladder Infection Diabetes Heart Disease High Blood Pressure Low Blood Pressure Mitral Valve Prolapse Stroke HIV or AIDS Infectious Mono Cancer Arthritis Hives or Eczema Acid Reflux Hemorrhoids Hepatitis Ulcer Kidney Disease Thyroid Disease Preventative Care: Most Recent Flu Vaccine: Most Recent Colonoscopy: Most Recent Mammogram [WOMEN]: Most Recent Pneumovax: Most Recent PSA Level [MEN]: Most Recent PAP Smear: Prior Radiation Therapy When Where Previous Hospitalizations / Surgeries / Serious Illnesses When Where

4 Surgeries & Procedures (Please check all that apply and provide dates if possible) SURGERY DATE WHERE (Name of Hospital) Tonsillectomy Appendectomy Hernia Repair Eye Surgery [Including Cataracts] Cholecystectomy [Gallbladder Removal] Bowel Surgery Recal Surgery Hemorrhoid Gastric Bypass Lung Surgery Heart Surgery Heart Stent Placement Angioplasty Plastic Surgery Thyroid Breast Removal /Biopsy Hysterectomy Other Gynecological Surgery Tubal Ligation Prostate Surgery or Biopsies D & C Vasectomy Bladder Surgery Knee or Hip Replacement Head or Neck Surgery Vascular Proc on Extremity SURGEON Family Medical History: Age Diseases If deceased, cause of death Father Mother Sibling(s) Spouse Children

5 Please check whether you have had any of these problems in the past 3 months: Constitutional Symptoms Genitourinary Psychiatric Good general health Frequent Urination Memory loss or confusion Recent weight gain / loss Burning or painful urination Extended periods of sadness Fever Blood in urine Nervousness Fatigue Change of force of stream when urinating It would be ok if I fell asleep and never woke up Night Sweats Dribbling or incontinence Sleep too much / Too Little Eyes Incontinence when coughing or Eat too much / Too little laughing Eye disease or injury Kidney Stones Endocrine Blurred or double vision Sexual Difficulty Hormone Problems Wear glasses / contacts Male Testicular Pain Excessive Thirst Ear /Nose /Mouth /Throat Female Last Menstrual Cycle: Excessive urination Hearing loss or ringing Female- Pain with period Excessive desire to eat Earache or drainage Female Irregular Period Hot or cold intolerance Chronic sinus problem Female-Vaginal Discharge Skin is dry and flaky Nose Bleeds Female Number of pregnancies: Change in hat or glove size Mouth Sores Female- Number of Miscarriages: Female Hair is thinning or balding Bleeding Gums Musculoskeletal Hematologic/Lymphatic Bad breath or bad taste Joint Pain Slow to heal after cuts Sore throat or voice change Joint stiffness or swelling Bleeding or bruising tendency Swollen glands in neck Weakness of muscles or joints Anemia Cardiovascular Muscle pain or cramps Enlarged lymph nodes Chest pain Difficulty Walking Allergic / Immunologic Palpitation Cold Extremities Certain foods Shortness of breath while walking Pain anywhere in your body Environment Shortness of breath while Detergents Integumentary / Skin lying flat Swelling of feet, ankles or Rash or itchy skin Soaps hands Respiratory Change in skin color Lotions Shortness of breath Change in hair or nails Iodine Chronic coughing Varicose Veins Shellfish Wheezing Breast Pain Penicillin or other antibiotics Coughing up blood Breast Lump Narcotics Use of oxygen Breast Discharge Other drugs Gastrointestinal Neurological Loss of appetite Frequent or recurring headaches Nausea Light headed or dizzy Vomiting Convulsions or seizures Diarrhea Numbness or tingling Constipation Tremors Abdominal Pain Paralysis Blood in stool Head Injury Indigestion

6 Patient Social History: Marital Status: Single Married Separated Divorced Widowed Use of Alcohol: Never Rarely Moderately Daily Use of Tobacco: Never Currently [How many a day: ] Quit [Years of Use ] Use of Illegal Drugs: Never Yes Type of Drug(s): Years of Use: Excessive exposure at home / work to: Fumes Solvents Air-born Particles Dust Noise What is your usual weight? Do you use assistive devices (ex: walker, wheelchair, cane, oxygen) Yes No If yes, please describe: To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be detrimental to my health. It is my responsibility to inform the staff at the Alvin & Lois Lapidus Cancer Institute of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I need. Signature of Patient / Parent / Responsible Party Date