John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter

Transcription

1 John Wayne Cancer Institute Dr. Foshag Essner Dr. Fischer Dr. Faries Dr. Foshag Dr. Bilchik Dr. O'Day Dr. Leuchter Medical Questionnaire Reset Form Date: Name: Gender: Male Female Age: Last First Middle Birth-date: Birth Place: Mother s Birth Name: Social Security #: - - Driver s License #: Marital Status: Single Married Spouse s Name Married how long? Divorced Separated Widowed Language Spoken: Interpreter Required? Home Address: City: State: Zip-code: - Phone: Fax: Employer: Occupation: Address: Phone: City: State: Zip-code: - Fax: Emergency Contact: Relationship: (t living in the same household) Address: City: State: Zip-code: Fax: Local Telephone Number: (Relative, Friend or Hotel) Referring Physician: Specialty: Address: City: State: Zip-code: - Phone: Fax: Send periodic report* Other Physician: Specialty: Address: City: State: Zip-code: - Phone: Fax: Send periodic report* Other Physician: Specialty: Address: City: State: Zip-code: - Phone: Fax: Send periodic report* * Periodic reports may be sent to your physician(s). Please check box of any physician you wish to receive reports. Page 1 of 10

2 Date of Birth: Date: Height: Weight: SS #: Spouse s Name: Allergies Category Do t List Allergies Explain Reaction Drugs Food Environmental Medical History: Bleeding Dizziness / Fainting Infectious Disease Shortness of Breath Blood Disease Edema Kidney Disease Skin Bone Disorder Gastrointestinal Mental Illness Stroke Cancer Heart Disease Pain Thyroid Disorder Chipped / Loose Teeth Hypertension Pulmonary Disease Personal History of Anesthesia problems Dentures Implanted Device (Shunt, Pump, Pacemaker) Seizures Family History of Anesthesia problems Diabetes **For Women: Date of Last Menstrual Period (LMP): Please list and describe any previous Hospitalization and / or Surgeries: Have you or family members had a previous history of anesthesia problems? (Explain) Do you: Smoke: Amount: Consume Alcohol: Amount: Medications Name of Medication Dose Frequency Page 2 of 10 Last Dose Comments

3 Please indicate if you have had or currently are experiencing any of the following. If you are not sure, please mark Do t and we will be happy to assist you during your scheduled visit. GENERAL Swollen or enlarged (lymph) glands Diabetes Other tumors or cancer Mumps Rheumatic fever Scarlet fever Nervous disorders Gallbladder disease 9. Venereal disease 10. Hepatitis 1 Cirrhosis 1 Epilepsy Do t Do t HEAD, EYES, EARS, NOSE, THROAT (HEENT) Headaches Dizziness or fainting spells Eye injuries Double vision Blurring vision Eye pain Cataracts Glaucoma 9. Earaches 10. Ringing or buzzing in ear 1 Decrease / loss of hearing 1 Sensation of spinning 1 Sinus trouble 1 se bleeding 1 Sore tongue 1 Bleeding gums 1 Unusual trouble with teeth 1 Skin disease 19. Skin tumors / moles removed or burned 20. Chronic or frequent infections, colds Page 3 of 10

4 ENDOCRINE Thyroid trouble or goiter Thyroid medication or tests Frequent Laryngitis Hoarseness or change in voice Do t Do t Do t Do t BREAST Lumps in breast Pain in breast Nipple discharge HEART Heart Disease Bleeding tendency or easy bleeding High Blood pressure Pain or pressure in chest Undue shortness in breath (day or night) Ankle Swelling Pain in legs while walking Fast or irregular heart beating (palpitations) 9. Heart murmurs PULMONARY Chronic cough, coughed up blood Do you have the date of your last chest x-ray? Soaking sweats Exposure to TB Asthma Page 4 of 10

5 GASTROINTESTINAL Do t Do t Do t Do t Stomach, liver or intestinal trouble Recent gain or loss of weight. (lbs.) Gain Loss Decreased appetite Difficulty swallowing Nausea or vomiting Frequent bowel movements Constipation Recent change in bowel movements 9. Black bowel movements 10. Blood in stools 1 Jaundice GENITOURINARY URINARY Kidney trouble Frequent or painful urination Kidney stones Blood in urine Sugar or albumin in urine Slow starting of urine stream Passing urine at night MUSCULOSKELETAL Arthritis or rheumatism Back or bone pain Clumsiness / awkwardness of hands / feet Numbness or tingling of hands or feet Muscle pain or weakness NEUROLOGIC Forgetfulness Reactions to serum, drug or medicine Unusual fatigue Excessive worry Excessive depression Nervous disorders Sexual impotence Seizures 9. Strokes Page 5 of 10

6 Women Only GYNECOLOGICAL Vaginal bleeding following intercourse Painful menstruation Irregular or excessive menstruation Vaginal discharge Been treated for female disorder Have you used an intrauterine device Have you gone through menopause Do t Please list any past breast problems: Are you taking hormones: Have you ever taken birth control pills or hormones? Type: How long? When stopped? Age of onset of menstruation: Interval between periods: Date of last period: Number of pregnancies: Number of births: Number of abortions: Your age at birth of your first child: Family history of breast problems Date of your Last Menstrual Cycle (LMC): Page 6 of 10

7 Past Surgeries (Operations): Please list in chronological order DATE TYPE OF OPERATION REASON FOR SURGERY HOSPITAL DOCTOR Other Hospitalizations: Please list in chronological order DATE TYPE HOSPITAL DOCTOR Radiation Therapy Treatment: Please list in chronological order. We need to know when treatment started and when it was completed. STARTED? Month Year STOPPED? Month Year AREA OF BODY TREATED Page 7 of 10 HOSPITAL DOCTOR

8 Family History RELATION AGE STATE OF HEALTH Father Mother Spouse Brothers Sisters Children Page 8 of 10 IF DECEASED CAUSE OF DEATH AGE AT DEATH

9 Have any of your blood relatives, husband, wife or children had any of the following? (CHECK EACH ITEM) RELATION(S) Tuberculosis Diabetes Cancer Leukemia Anemia Bleeding Tendency Heart Disease High Blood Pressure Kidney Disease Asthma, Hay Fever, Other Allergy Chronic Arthritis (Rheumatism) Nervous Or Mental Disorder Goiter Emphysema Any Other Illness Page 9 of 10

10 Billing Information Billing Information: Self-Pay Insurance Other Insurance Company Policy #: Supplementary Ins. Co.: Policy#: Type of Insurance Coverage: Insurance Company HMO PPO Indemnity Other Supplementing: Type of Insurance Coverage: HMO PPO Indemnity Other Name of Insured: Social Security # of Insured: If you are not the insured indicated above, your name: We would like to know how you selected the John Wayne Cancer Institute: Physician referred; I asked my physician to refer me; A friend or relative referred me; I referred myself; Other: Page 10 of 10