Margie Petersen Breast Center
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1 Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced Separated Widowed Ethnicity: White/Caucasian Black/African-American Native Hawaiian or other Pacific Islander Date: Ashkenazi Jewish Heritage Asian American Indian or Alaska Native Hispanic/Latina Other: Home Address: Home Phone: ( ) Driver s License #: Cell Phone: ( ) Employer/Business Name: Occupation: Business Address: Business Phone: ( ) If retired or disabled, since when? Emergency contact: Relationship: Address: Phone: ( ) Please provide your physicians information below so that we may send reports: Referring Physician: 1) Name: Phone: ( ) Address: Other Physicians: 2) Name: Phone: ( ) Address: 3) Name: Phone: ( ) Address: Who is to be billed for your consultation and treatment? Insurance 1 Insurance 2 Self-Pay We would like to know how you selected the at Providence Saint John s Health Center: My physician recommended I come I asked my physician to refer me I referred myself A friend or relative referred me Other: Page 1 of 9
2 History of your present health problem or illness for which you are seeking care at the at Providence Saint John s Health Center: Please describe briefly, in your own words, the date of onset of your current problem or illness, any symptoms you have experienced, and the dates of any tests and/or treatment(s), with the names and addresses of physicians whom you have consulted. Page 2 of 9
3 Do you now have or have you ever had any of the following? Condition Yes No 1. Epilepsy 2. Headaches 3. Dizziness or fainting spells 4. Eye injuries 5. Double vision 6. Blurred vision 7. Eye pain 8. Cataracts 9. Glaucoma 10. Earaches 11. Ringing or buzzing in ear 12. Decrease or loss of hearing 13. Sensation of spinning 14. Sinus trouble 15. Nose bleeding 16. Sore tongue 17. Unusual trouble with teeth 18. Skin disease 19. Skin tumors or moles removed or burned 20. Diabetes 21. Thyroid trouble or goiter 22. Thyroid tests or medication 23. Frequent laryngitis 24. Hoarseness or change in voice 25. Bleeding gums 26. Bleeding tendency or easy bleeding/bruising 27. Other tumors or cancer 28. Tuberculosis 29. Mumps 30. Rheumatic fever 31. Scarlet fever 32. Venereal disease 33. Swollen or enlarged (lymph) glands 34. Lumps in breast 35. Pain in breast 36. Nipple discharge 37. Heart disease 38. High blood pressure 39. Pain or pressure in chest 40. Undue shortness of breath (day or night) 41. Ankle swelling 42. Pain in legs while walking Do Not Know Page 3 of 9
4 Do you now have or have you ever had any of the following? Condition Yes No 43. Fast or irregular heartbeat (palpitations) 44. Heart murmurs 45. Chronic cough, coughing up blood 46. When was your last X-ray? Mo/Yr Never 47. Soaking sweats 48. Asthma 49. Excessive worry or depression 50. Nervous disorders 51. Stomach, liver, or intestinal trouble 52. Recent gain or loss of weight Gained lbs Lost lbs 53. Decreased appetite 54. Difficulty swallowing 55. Nausea or vomiting 56. Indigestion or heartburn 57. Gallbladder disease 58. Hepatitis 59. Cirrhosis 60. Frequent bowel movements 61. Constipation 62. Recent change in bowel movements 63. Black bowel movements 64. Blood in stools 65. Jaundice 66. Kidney trouble 67. Frequent or painful urination 68. Kidney stones or blood in urine 69. Sugar or albumin in urine 70. Slow starting of urine stream 71. Passing urine at night 72. Arthritis or rheumatism 73. Back or bone pain 74. Clumsiness or awkwardness of hands or feet 75. Numbness or tingling of hands or feet 76. Muscle pain or weakness 77. Forgetfulness 78. Nervous disorders 79. Any reactions to serum, drug or medicine 80. Unusual fatigue 81. Insomnia, sleep problems 82. (MEN) Sexual impotence 83. Daily alcohol intake: beer wine liquor other: 84. Smoke cigarettes. If yes, packs per day Do Not Know Page 4 of 9
5 Women Only: Do you now have or have you ever had any of the following? 85. Vaginal bleeding after intercourse 86. Painful menstruation 87. Irregular or excessive menstruation 88. Vaginal discharge 89. Been treated for a female disorder 90. Intrauterine device (IUD) 91. Gone through menopause Condition Yes No Do Not Know Past breast problems (list): Right/Left Side Type of Problem When Have you ever taken hormones? Yes No Don t Know If yes, which ones and for how long? Hormone When started? When stopped? Birth Control Pills Estrogen Tamoxifen Evista (Raloxifene) Other: Age of onset of menstruation: Interval between periods: Duration of periods: Date of last period: Number of pregnancies: Number of births: Number of miscarriages: Number of abortions: Age at first childbirth: Family history of breast problems: Page 5 of 9
6 Past Surgery (Operations): Please list in chronological order MONTH YEAR TYPE OF OPERATION REASON FOR SURGERY HOSPITAL DOCTOR Chronic Medical Problems: DESCRIPTION YEAR DIAGNOSED TREATMENT DOCTOR Other Hospitalizations: Please list in chronological order MONTH YEAR TYPE HOSPITAL DOCTOR Page 6 of 9
7 Are you allergic to any medicines? Yes* No *Please list any medications to which you have had an allergic reaction, and the type of reaction: Are you allergic to any foods? Yes* No *Please list any foods to which you have had an allergic reaction, and the type of reaction: Please list any medications you are now taking: Name of Medication Dosage Frequency Hormones or Birth Control Pills: Antidepressant/Antianxiety Pills: Tranquilizers/Sleeping Pills: Pain Pills: Other: Please list or describe any other therapies, vitamins, or herbal remedies you are taking currently, why & how you take each (such as frequency and amount): (if you need more space, please continue on the back) Name of Vitamin, Herb or Therapy Purpose Dosage & Frequency When Started Past Radiation Therapy Treatment: Please list in chronological order. We need to know when treatment started and when it was completed. STARTED? STOPPED? Month Year Month Year AREA OF BODY TREATED HOSPITAL DOCTOR Page 7 of 9
8 Family History RELATION AGE STATE OF HEALTH IF DECEASED CAUSE OF DEATH AGE AT DIAGNOSIS AGE AT DEATH Father Mother Spouse Brothers Sisters Children Grandparents Page 8 of 9
9 Family History (continued) Have any of your blood relatives (both mother s and father s sides), spouse, or children had: Yes No (CHECK EACH ITEM) RELATION(S) Tuberculosis Diabetes Cancer Breast... Ovarian... Colon... Prostate... Other 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 9
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Charleston Hematology Oncology Associates, PA Medical History
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Gender: M F Race: Caucasian African American Hispanic Other
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PULMONARY MEDICINE PATIENT QUESTIONNAIRE
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THE OB/GYN CENTRE NEW PATIENT HISTORY
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NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE PLEASE PRINT Full name: Age: Preferred Contact number: Email address: Why are you here today? To establish primary care Annual exam Consultation from another doctor If consultation,
*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months
*542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only