SANTA MONICA BREAST CENTER INTAKE FORM
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1 SANTA MONICA BREAST CENTER Who referred you to see us today? Who is your primary care physician? Are there any other MDs who you would like to receive today s visit information? No Yes MD contact info (if outside UCLA): Please indicate any Breast Symptoms you are currently experiencing: Mass or Lump: No Yes Nipple Discharge: No Yes Skin Changes: No Yes Breast Pain: No Yes Other: Have you been having regular mammograms? No Yes - How often? Do you do breast self-examination? No Yes - How often? Prior to the current, have you ever had a previous breast biopsy? No Yes Prior to the current, have you had prior breast? No Yes If yes, year diagnosed: Was your prior breast, Right Breast Left Breast How was your prior breast treated? Lumpectomy Mastectomy If mastectomy, did you have reconstruction? No Yes Did you have axillary surgery? No Yes What type: Complete axillary lymph node dissection Sentinel lymph node biopsy Did you receive radiation therapy? No Yes If yes, when? Did you receive chemotherapy? No Yes Did you receive hormone/endocrine therapy? No Yes Have you ever had breast reduction surgery? No Yes What year? Have you ever had breast augmentation surgery? No Yes What year? Allergies: Do you have any allergies? No Yes UCLA Form # Rev. (4/16) Page 1 of 5
2 SANTA MONICA BREAST CENTER Please list all allergies to medications/foods/substances/ what type of reaction you had: Allergy/Medication Reaction Medications list all medications/vitamins/supplements you are currently taking/dose/frequency: Medication Dose/Frequency Prescribing Physician Operations and Hospitalizations Please list all operations and hospitalizations, if applicable Surgery/Hospitalization Date Medical History Please list all medical diagnoses/conditions you see doctors for or take medicines for: UCLA Form # Rev. (4/16) Page 2 of 5
3 SANTA MONICA BREAST CENTER FAMILY HISTORY Are you of Ashkenazi Jewish Descent: No Yes Do you have a family history of breast? No Yes Unknown If yes, which family member(s)? Relative Current Medical Problems History of, type, Do you have a family history of ovarian? No Yes Unknown If yes, which family member(s)? Relative Current Medical Problems History of, type, Do you have a family history of other s? No Yes Unknown If yes, which family member(s)? Relative Current Medical Problems History of, type, UCLA Form # Rev. (4/16) Page 3 of 5
4 SANTA MONICA BREAST CENTER GYNECOLOGIC HISTORY time of first menstrual cycle (first period): Last menstrual period? Have you experienced menopause? No Yes menopause: Have you had a hysterectomy? No Yes How many pregnancies have you had? Were your ovaries removed? No Yes How many live births you had? If premenopausal, is there any possibility that you could be pregnant? No Yes How old were you when you first child was born? Did you Breastfeed? No Yes Have you ever taken hormone replacement therapy? No Yes Age started: Age stopped: Have you ever used hormonal contraceptive methods? No Yes Age started: Age stopped: Have you ever had fertility s? No Yes PERSONAL/SOCIAL HISTORY Ethnicity: Caucasian African American Spanish/Hispanic American Indian/Aleutian/Eskimo Asian/Pacific Islander Other Marital Status: Single Married Domestic Partnership Divorced Widowed Do you have children? No Yes If yes, what are their ages? Are you currently employed? No Yes If yes, what is your occupation? Have you been or are you currently a cigarette smoker: No Yes If yes, how many years did you smoke? How much? Are you currently smoking? No Yes If you have quit smoking, how long ago did you quit? pack/day Do you drink alcohol? No Yes Number of drinks per day: per week: Describe your daily activity level: (Mark only ONE that best describes you now): I am fully active and am able to carry on all usual activities without restriction I am restricted in physically strenuous activity, but can walk and am able to carry on light housework I can walk and take care of myself, but am unable to carry out work activities I need help taking care of myself and I spend more than half of the day in bed or a chair I cannot take care of myself at all and spend most of the day in bed UCLA Form # Rev. (4/16) Page 4 of 5
5 FORM TITLE FORM TITLE Specialty/Department (if necessary) REVIEW OF SYSTEMS: Please check off below any symptoms or problems you are currently having: Constitutional poor appetite fatigue weight gain/loss poor sleep fever headache Eyes blurred vision double vision tearing/watery eyes sensitivity to light Ears, nose, mouth & throat difficulty hearing ringing in ears sinus problems nose bleeds dry mouth taste changes hoarseness pain with swallowing difficulty with swallowing Cardiovascular chest pain irregular heart beat high blood pressure swelling of feet or ankles heart murmur Pacemaker Respiratory shortness of breath cough coughing up blood asthma or wheezing Gastrointestinal abdominal pain diarrhea constipation heartburn or indigestion nausea vomiting Blood in stools Genitourinary frequent urination painful urination blood in urine leakage/ incontinence vaginal dryness Neurologic headaches dizziness memory loss problems walking/ falls numbness/ tingling Psychiatric depression anxiety Hematologic/ lymphatic enlarged lymph nodes arm swelling Skin itching easy bruising rash Endocrine hot flashes change in tolerance to hot or cold weather excessive thirst night sweats chills Allergic/ Immunologic allergies runny nose itchy eyes Musculoskeletal bone pain joint pain muscle weakness Patient or Representative Signature Date Time If signed by someone other than the patient, please specify relationship to the patient Interpreter Signature ID # Date Time UCLA Form # Rev. (4/16) Page 5 of 5
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address:
SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE
Patient Name MRN DATE: SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE Date of birth Age REASON FOR VISIT Abnormal Mammogram R L please specify Lump/Thickening R L upper lower inner outer Pain R L upper
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
FIRST TIME VISIT APPOINTMENT CHECKLIST Department of Radiation Oncology 200 Medical Plaza, Ste B265 Los Angeles, CA
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Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
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
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725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
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Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Address: May we leave a
Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Email Address: May we leave a message? Home Work Cell PLEASE DO NOT LEAVE A MESSAGE Marital
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Patient Name Date of Birth Thank you for choosing Southern Cancer Center for your care. To help us best prepare for your appointment, please complete this form and bring it to your appointment. If you
visit: our office: Yes If so, how often? 3. Have you Yes 4. Have you ever been Noo If so, how Yes No often? MRI? What facility? cancer? 1.
( Label) 1. Main reason for this visit: 2. Who referred you to our office: 3. Please list any treating physicians: 4. Age: Height: Weight: Bra Size (if female): BREAST HISTORY 1. Do you perform breast
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DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
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WELCOME TO OUR OFFICE
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