SUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth:
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- Leo Terry
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1 Name: Date of Birth: What is the reason for your visit today? What doctor referred you to this office? PAST MEDICAL HISTORY: Do you have any of the following: Please check all that apply Anxiety /depression Asthma Atrial Fibrillation BPH (enlarged prostate) Cirrhosis COPD (or emphysema) Diabetes GERD (heartburn/indigestion Hepatitis High Cholesterol HTN (high blood pressure) MI (heart attack) Thyroid- (low or high) Osteoarthritis Seizures Stroke DVT (blood clot in leg) PE (pulmonary embolism) SURGICAL HISTORY Appendectomy (appendix out) Biopsy of C-Section Cataract Removal Colonoscopy Coronary Bypass Hysterectomy (uterus removed) Ovaries Removed Laminectomy (spine surgery) Kyphoplasty (spine surgery with cement) Pacemaker Tonsillectomy Tubal Ligation (tubes tied) Knee Replacement Hip Replacement Rotator Cuff Repair Cholecystectomy (gallbladder out) OTHER: FOR WOMEN: How many pregnancies Last pap smear How many live births Last mammogram Age at first birth Age of menopause # of interrupted pregnancies Reason: Natural Surgery Other (circle one) Age at first period Last menstrual period every days 1. RN Initials:
2 FAMILY HISTORY: Please complete the section in its entirety and provide as much detailed information as possible. RELATIVE Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother Mother Father Aunts (w/cancer) Uncles (w/cancer) Sisters (Total # ) MEDICAL PROBLEMS: (i.e. heart failure, breast cancer, etc.) Age at Diagnosis Deceased? Age at Death Brothers (Total # ) Children (please list ages of all children) Spouse 2. RN Initials:
3 SOCIAL HISTORY: Please check all that apply: SUSQUEHANNA HEALTH CANCER CENTER DO YOU: Currently smoke? Pipe Cigarettes HOW MUCH Ex: 1 pack a day or 6 beers a month HOW OFTEN Ex:1 pack a day or 6 beers a month HOW LONG NO Did you ever smoke? Yes No Quit date: Chew Tobacco? Yes No Drink Alcohol? Beer Wine (Even if it s only social) Liquor Never Mobility: Ambulate independently with cane, walker or wheelchair bound? Occupation: How long? Hobbies: (i.e.painting,gardening) Exercise (i.e.walking Were you ever exposed to toxins/chemicals? Yes No If yes, what were you exposed to: Do you follow a special diet? Circle any that apply REGULAR/ SOFT/FEEDING TUBE/LIQUID/SUPPLEMENTS/Diabetic Are you: Married Single Divorced Widow Do you live: Alone With spouse/significant other With family Do you feel safe in your home? Yes No Do you have thoughts of harming yourself? Yes No Will you need assistance traveling to and from the Cancer Center? Yes No Are you having financial worries about your testing or potential treatment: Yes No Do you have a Living Will/Advance Directive? Yes No Would you like to speak with someone about a Living Will/Advance Directive? Yes No Do you have a Healthcare Power of Attorney? Yes No ALLERGIES: Please list all medication allergies and the reaction: No Medication Allergies RN Initials:
4 RETAIL AND/OR MAILORDER PHARMACY PHARMACY NAME: MAIL ORDER COMPANY: MEDICATION LIST: Please list ALL medications you take, including over the counter medications/supplements MEDICATION DOSE ROUTE (by mouth, injection) FREQUENCY
5 RN Initials: Review of Systems: Please check YES to those that apply Constitutional SYMPTOM YES Please Explain LOSS OF APPETITE WEIGHT LOSS SHAKING CHILLS NIGHT SWEATS FEVER Eyes BLURRED VISION DOUBLE VISION CATARACTS GLAUCOMA ENMT HEARING LOSS DYSPHAGIA (pain swallowing) DRY MOUTH MOUTH SORES SINUS INFECTIONS EPISTAXIS Endocrine DIABETES HOT FLASHES THYROID DISEASE Hem/Lymph BLEEDING BLOOD CLOT BRUISING
6 HISTORY OF ANEMAI/LOW BLOOD TRANSFUSIONS 5. ENLARGED LYMPH NODES Breast BREAST MASSES NIPPLE DISCHARGE NIPPLE INVERSION BREAST PAIN Respiratory COUGH SPUTUM PRODUCTION SHORTNESS OF BREATH WHEEZING COUGHING BLOOD Cardio CHEST PAIN PALPITATIONS ANKLE SWELLING GI ABDOMINAL PAIN DIARRHEA CONSTIPATION HEARTBURN VOMITING BLACK STOOLS BLOOD IN STOOLS HEMORRHOIDS HERNIA GU BURNING WITH URINATION URINARY FREQUENCY
7 Musculoskeletal ARTHRITIS BONE PAIN MUSCLE WEAKNESS Skin/Integ DRY SKIN ITCHING RASH HIVES Neuro DIZZINESS HEADACHE PARALYSIS Psych DEPRESSION ANXIETY Other: Please provide us with your cell phone#: Please provide us with your address: 7. RN Initials:
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
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