MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM
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1 MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM Name: Date Reason for Consultation: Physicians involved in your care: Best Contact Phone #: Can we leave a message: YES NO Please check any current problems/symptoms: GENERAL /CONSTITUTIONAL CARDIO/PULMONARY Fatigue Fever/Chills Hot flashes/night sweats Loss of appetite Sleep problems Weight loss Weight gain Chest pain Cough Coughing blood Heart palpitations Shortness of breath NEUROLOGICAL MUSCULOSKELETAL INFECTIONS Difficulty walking Aids used for mobility: Bone Pain Jerking or twitching Joint pain/swelling Muscle weakness Dizziness Fainting Spells Headaches Numbness/Tingling Seizures SKIN/INTEGUMENTARY Itching Rash MRSA/VDRL/C-DIFF Risk of HIV exposure
2 NAME DATE GI/NUTRITIONAL Abdominal Pain Change in bowel habits Constipation Diarrhea Nausea/Vomiting Rectal pain/bleeding Special Diet Swallowing Problems Taste Changes URINARY Blood in urine Difficulty with urinary control Painful urination Urgency Urinary Frequency Urinating at night Urinary tract infection GYN/REPRODUCTION Changes in menstrual cycle Changes in sexual function Post- menopausal bleeding Vaginal bleeding Vaginal discharge EYES/EARS/NOSE/THROAT Earache/drainage Hearing problems Nose bleeds Sore throat Trouble swallowing Visual problems HEMATOLOGICAL/LYMPHATIC Easy bruising/bleeding Enlarged lymph nodes Lymphedema Anemia Blood disorders Blood Transfusion PSYCHOSOCIAL Anxiety Claustrophobia Confusion Depression Panic attacks
3 NAME DATE PAST MEDICAL HISTORY CARDIO/NEUROLOGICAL CVA/Stroke Seizures Heart Attack High blood pressure High Cholesterol Irregular heart rhythm Mitral valve prolapse Palpitation Varicose veins Vascular problems MUSCULOSKELETAL Arthritis Fibromyalgia Osteoarthritis Rheumatoid Arthritis IMPLANTABLE DEVICES Defibrillator: Date inserted Pacemaker: Date inserted Port: Date inserted URINARY ENDOCRINE/DIABETES Diabetes Thyroid problems Other endocrine disorders PULMONARY Asthma Chronic Bronchitis COPD Emphysema Nebulizer Oxygen/CPAP/BiPap Pneumonia Sleep apnea Tuberculosis GI/NUTRITIONAL Cirrhosis of the Liver Colitis Feeding Tube GERD/Heart Burn Hepatitis Irritable bowel syndrome Ulcer Dialysis Enlarged Prostate Kidney Stones Prostate hormone treatment
4 NAME PERSONAL HISTORY Married/Single/Widow/Divorced Currently Working YES NO Retired YES NO Adequate Transportation YES NO Living Will YES NO Durable Power of Healthcare Attorney Do you want information On Living Will or Durable Power of Healthcare Attorney? Where do you live? YES NO YES NO Home Nursing Facility Assisted Living How many people live in your home? GYNECOLOGICAL HISTORY Age of first period Age of first birth # of pregnancies # of live births Date of last menstrual period Date of last mammogram Date of last pap test Currently using birth control YES NO Which type Contraceptive hormone use YES NO # of years Post menopause hormone use YES NO # of years DATE SOCIAL LIFESTYLE No tobacco use Active tobacco Use Packs/day Occasional tobacco use Packs/day Former tobacco use Years quit Packs/day No recreational drug use Recreational drug use Type Former recreational drug use/type Years quit No alcohol use Active alcohol use # of days/week Occasional alcohol use #of drinks/year Former alcohol use Years quit Personal History of Cancer YES NO Previous Chemotherapy/Radiation YES NO
5 NAME DATE SURGERY HISTORY Surgery Date FAMILY HISTORY Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Siblings/Other LIVING DECEASED AGE ILLNESSES
6 NAME DATE MEDICATION LOG Medication Dose Schedule (How Taken) Doctor who prescribed Allergies Reaction
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MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
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