The Rehabilitation Institute Cancer Rehabilitation
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1 DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation STAR Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors names and addresses (primary care physician and oncology physicians and any other doctors whom you want to receive information about your rehabilitation): History of Present Illness: Date of first cancer diagnosis: Date: Type & Stage: Treatment for first cancer diagnosis (list what you have undergone, are curently undergoing, and what you expect to undergo in the future): Date of second cancer diagnosis or cancer recurrance and type and stage of cancer: Treatment for second cancer diagnosis or cancer recurrance (list what you have undergone, are curently undergoing, and what you expect to undergo in the future): List any problems you are having as a result of cancer treatment: Current Medications (list all medications including over the counter/supplements/vitamins): ergies to Medications (list all medication allergies and the type of reaction that you had): PAGE 1
2 PAGE 2 Past Medical History (list any medical conditions you have that you have not already described, e.g., diabetes, high blood pressure, etc.): Past Surgical History (list any surgeries you have had in the past, including the date): Social/Functional History (Describe your current work status and any limitations you have regarding work): Describe your current living situation (e.g. who do you live with, what kind of dwelling do you live in, etc.): Do you have children (if so, how old are they)?: Describe any limitations you have in your daily activities: Describe any limitations you have in tasks such as preparing meals, grocery shopping, yard work and other household chores: Describe any limitations you have in recreational activities: Describe your exercise regimen and any limitations you have regarding exercise: How much alcohol do you drink?: Do you smoke now or have you in the past? (please explain) Where do you get support? What are your rehabilitation goals? _ Family History: (list medical problems that run in your family and who they affect): Height: ft. in. Current Weight: lbs. Weight one year ago: lbs.
3 REVIEW OF SYSTEMS Check the box if you have or haver ever had any of these problems: Frequent fevers Congestive heart failure Gout Night sweats Bronchitis / pneumonia Rashes / eczema/ psoriasus Unexplained weight loss Chronic cough Skin growths / lesions / lumps Unexplained weight gain COPD / emphysema Difficulty healing Insomnia Snoring or sleep apnea Drainage from nipple Chronic fatigue Shortness of breath Fainting / dizziness Daytime sleepiness Frequent indigestion / reflux Tremors / shakes Wear glasses / contacts Nausea / vomiting Tingling / numbness Eye pain Hiatal hernia Muscle weakness Dry eyes Inguinal hernia Stroke / paralysis Excessive tearing Stomach ulcers Concussion / head injury Double vision Jaundice / liver disease Memory problems Blurred vision Hepatitis Personality changes Light sensitivity Hemorrhoids Headaches Glaucoma Blood in stool Seizures / epilepsy Hearing loss Bloating / excess gas Nervousness / anxiety Ringing in the ears Irritable bowel syndrome Addiction Sensitivity to noise Diverticulosis Depression Balance problems / vertigo Abdominal pain Suicidal thoughts Earaches / infections Constipation Panic disorder Sinus infections Diarrhea Claustrophobia Frequent colds / congestion Incontinence / dribble Victim of abuse Nose bleeds Decreased stream force Eating disorder Deviated septum Frequent urination Bipolar disorder Bleeding gums Difficulty / pain urinating Hallucinations Sore tongue Blood in urine ADD / ADHD Frequent sore throats Bladder or kidney infection Post-traumatic stress Mouth ulcers, bumps, lesions Kidney disease Psychiatric hospitalization Loss of taste or smell Kidney / bladder stones Heat or cold sensitivity Persistent hoarseness Neck pain Diabetes / high blood sugar Difficulty swallowing Mid back pain Low blood sugar High blood pressure Low back pain Heavy sweating Heart murmur Buttocks pain Thyroid disease Mitral valve prolapse Shoulder / arm / elbow / wrist / hand pain Obesity Palpitations / irregular heartbeat Hip / leg / knee / ankle / foot pain Abnormal menstrual cycle Leg cramps Muscle aches / spasms Decreased sex drive Swelling of feet or ankles Joint swelling / stiffness Anemia History of blood clots Broken bones Easy bruising Chest pain Joint dislocations Transfusion in the past History of heart attack Arthritis Family history of sickle cell HIV positive / AIDS Do you have significant fatigue? o Yes o No Do you have diminished energy? o Yes o No Do you have an increased need to rest, disproportionate to any recent change in activity level? o Yes o No PAGE 3
4 PAGE 4 VISUAL ANALOG SCALES FATIGUE SEVERITY (circle only ONE number per question) A. Rate how severe your fatigue is right now: B. Rate how severe your fatigue is on your worst day: C. Rate how severe your fatigue is on average: FACTIT-F (Version 4)* Below is a list of statements that other people with your illness have said are important. Please circle or mark one number per line to indicate your response as it applies to the past 7 days. PHYSICAL WELL-BEING GP1 I have a lack of energy GP2 I have nausea GP3 Because of my physical condition, I have trouble meeting the needs of my family GP4 I have pain GP5 I am bothered by side-effects of treatment GP6 I feel ill GP7 I am forced to spend time in bed SOCIAL / FAMILY WELL-BEING GS1 I feel close to my friends GS2 I get emotional support from my family GS3 I get support from my friends GS4 My family has accepted my illness GS5 I am satisfied with family communication about my illness GS6 I feel feel close to my partner (or the person who is my main support) Q1 Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it please mark this box o and go to the next section GS7 I am satisfied with my sex life
5 EMOTIONAL WELL-BEING GE1 I feel sad GE2 I am satisfied with how I am coping with my illness GE3 I am losing hope in the fight against my illness GE4 I feel nervous GE5 I worry about dying GE6 I worry that my condition will get worse FUNCTIONAL WELL-BEING GF1 I am able to work (include work at home) GF2 My work (include work at home) is fulfilling GF3 I am able to enjoy life GF4 I have accepted my illness GF5 I am sleeping well GF6 I am enjoying the things I usually do for fun GF7 I am content with the quality of my life right now ADDITIONAL CONCERNS HI7 I feel fatigued HI12 I feel weak all over An1 I feel listless ( washed out ) An2 I feel tired An3 I have trouble starting things because I am tired An4 I have trouble finishing things because I am tired An5 I have energy An7 I am am able to do my usual activities An8 I need to sleep during the day An12 I am too tired to eat An14 I need help doing my usual activities An15 I am frustrated be being too tired to do the things I want to do An16 I have to limit my social activity because I am tired PAIN SEVERITY (circle only ONE number per question) A. Rate how severe your pain is right now: (No pain) B. Rate how severe your pain is on your worst day: C. Rate how severe your pain is on average: PAGE 5 NGMC FORM # (8/17/12)
The Rehabilitation Institute Cancer Rehabilitation
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CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
PLAS/RECON SURGERY PATIENT HEALTH HISTORY
PLAS/RECON 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?
Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist
*All information is important to your intake and valuable to your personal treatment plan. Please answer as thorough as possible. Patient Information: Name: Date: / / (First Middle Last) Address: City:
Name Age Est Weight Height. In brief, why are you seeing the doctor today? List your allergies: List your medications, including dosages:
Date: Name Age Est Weight Height In brief, why are you seeing the doctor today? List your allergies: List your medications, including dosages: Previous Biopsies? Where Previous Surgery/Hospitalization/Injuries/Severe
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
Creve Coeur Family Medicine, LLC
Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal
Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:
Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY: