PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
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- Tamsin Bond
- 5 years ago
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1 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: Do you have any allergies to medications? Are you allergic to iodine/iv contrast dye? Prior History of Radiation Therapy Where in the body were you radiated? Approximate number of therapies? How many weeks? (one day, one week, 2-weeks, 3-weeks, 4-6 weeks): Location/Hospital/Clinic that provided radiation therapy: Prior History of Chemotherapy Currently on chemo or has completed chemotherapy in the last three months? Yes No o If YES, how many cycles have you completed? o If YES, date of last chemo dose: o Please list the names of chemo drugs you received: Cancer History Type Yes No Type Yes No Type Yes No Bladder Esophageal Skin Bone Leukemia Small Intestine Brain Lung Stomach Breast Ovarian Uterine Cervical Pancreatic Other Specify Colon Prostate UCLA Form # Rev. (8/17) Page 1 of 5
2 Medical History: Yes No Allergies Depression Myocardial Infarction Anemia Diabetes Mellitus Nerve/Muscle Disease Anxiety Emphysema Osteoporosis Arthritis GERD Seizures Asthma Glaucoma Sickle Cell Anemia Blood Transfusion Heart Murmur Stroke Cataracts HIV/AIDS Substance Abuse CHF Hypertension Thyroid Disease Clotting Disorder Kidney Disease Tuberculosis COPD Meningitis Ulcers Other Medical History: Surgical History: Appendectomy Cholecystectomy Back Surgery Hysterectomy Other Surgical History: Do you have any of the specific medical conditions listed below: Yes No Inflammatory Bowel Disease Crohn s Disease Ulcerative Colitis Lupus Scleroderma Claustrophobia Have you ever had: Yes No Previous Radiotherapy Previous Chemotherapy Gynecological (female patients only): Yes No Number of pregnancies: Have you ever taken oral contraceptives Number of children: Age at first live birth: Age periods first started: or hormone replacement medication? If yes, what type: Date of last Pap Smear: Age at menopause (if postmenopausal): Date of last Mammogram: Menopause Status: Premenopausal Postmenopausal Don t know UCLA Form # Rev. (8/17) Page 2 of 5
3 Family History: Yes No Have any of your family members ever had cancer? If yes, please list relationship and type of cancer in your family member(s): Social History: Smoking Yes No If you smoke currently or have smoked in the past: Never smoked Number years smoked Smoke currently Number packs per day Smoked previously Number years quit Alcohol Yes No If you drink alcohol currently or have done so in the Never drink alcohol past: Occasionally drink alcohol Number days drink/week Frequently drink alcohol Number drinks/day Number years quit Employment: Are you employed? Yes No If yes, what is your occupation: Support Systems: Yes No Do you live alone? Do you live with your spouse, significant other, family or friends? Do you live in your own house/apartment? Do you live in a nursing home? Do you live in an assisted living environment? Other comments: Transportation: Would transportation to UCLA Health for daily treatments be difficult for you? Yes No If Yes, please explain: UCLA Form # Rev. (8/17) Page 3 of 5
4 System Review: Please check yes or no box to indicate if you have any of the following: Immunology/Allergy Genitourinary (Female) Allergies to animals or plants Burning or painful urination Reactions (Runny Nose or itchy eyes) Frequent urination Cardiovascular Blood in urine Irregular heart beat (arrhythmias) Incontinence Chest Pain Frequent night time urination Difficulty walking two blocks (dyspnea) Kidney / bladder stones Swelling of hands, feet or ankles (edema) Sexual difficulty Shortness of breath while walking or lying Urgency with urination down (orthopnea) Urine color change Heart Murmur (palpitations) Vaginal discharge/bleeding Constitutional Vaginal spotting Poor appetite Genitourinary (Male) Fatigue Burning or painful urination Fevers Frequent urination Lethargy (sluggishness, sleepiness) Blood in urine Malaise (uneasiness) Impotence Night Sweats Incontinence Chills Frequent night time urination Recent Weight Change: Gain Loss Kidney / bladder stones If yes, amount: lbs Scrotal/testicular swelling Endocrine Urgency with urination Hot flashes Urine color change Menstrual irregularities Hematologic Intolerance to hot/cold (thyroid disease) Abnormal bruising or bleeding Ears, Nose & Throat Swollen glands (lymph nodes) Pain swallowing / Sore throat dysphagia) Skin Ear pain Blisters Nose bleeding (epistaxis) Abnormal itching (pruritus) Change in hearing ability Rash Mouth dryness Musculoskeletal Oral bleeding Inflammation of joints (arthritis) Ear infection (otitis) Bone Pain Sinus infection (sinusitis) Joint Pain Excessive sputum production Muscle weakness Taste changes Range of motion problems Ear ringing Psychiatric Voice change Depression Anxiety UCLA Form # Rev. (8/17) Page 4 of 5
5 System Review (continued): Please check yes or no box to indicate if you have any of the following: Ears, Nose & Throat Skin Pain swallowing / Sore throat dysphagia) Blisters Ear pain Abnormal itching (pruritus) Nose bleeding (epistaxis) Rash Change in hearing ability Musculoskeletal Mouth dryness Inflammation of joints (arthritis) Oral bleeding Bone Pain Ear infection (otitis) Joint Pain Sinus infection (sinusitis) Muscle weakness Excessive sputum production Range of motion problems Taste changes Psychiatric Ear ringing Depression Voice change Anxiety Eyes Respiratory Blurred vision Cough Double vision Blood in sputum (hemoptysis) Excessive tearing (lacrimation) Neurological Night blindness Disorientation Excessive light sensitivity (photophobia) Dizziness Other visual difficulties/changes in vision Gait problems Gastrointestinal Headaches Abdominal pain Insomnia Recent change in bowel habits Memory loss Constipation Motor weakness Frequent diarrhea Paralysis Heartburn or indigestion Convulsions (seizures) Fresh blood in stools Sensory problems Hemorrhoids Stroke Black stools Nausea Vomiting 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. (8/17) Page 5 of 5
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Patient Interview Form
Page 1 of 5 Orange Coast Memorial Office: 18111 Brookhurst Ave. Suite 5200, Fountain Valley, CA 92708 * Tel: (714) 962-7705 * Fax: (714) 861-4552 www.unitedgi.com Patient Interview Form Patient Information
DEPARTMENT OF MEDICINE Outpatient Intake Form
NAME: Last First Middle Initial Date of Birth: ADDRESS: HOME PHONE: WORK PHONE: Did someone refer you here? Yes No If yes, please give name: Main reason for your visit today: MEDICAL HISTORY: (Please check
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM
NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM Today s Date: Name: Date of Birth: Race: American Indian or Alaskan Native Asian Black or African-American More
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
![Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?](/thumbs/87/97078208.jpg "Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?")
ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
Patient registration
Patient registration Name: DOB: Sex: Date: Who referred you to our office? Other Physicians you see: Occupation: Place of Employment: Marital Status (Please Circle): Single Married Separated Divorced Widowed
VASCULAR SURGERY PATIENT HEALTH HISTORY
VASCULAR SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications? To