Patient Health Questionnaire

Transcription

1 For Office Use Only: Medical Record #: HRBC#: Patient Health Questionnaire Today s Date: / / Last Name: First Name: Middle Initial: Date of Birth: / / Social Security Number: Mailing Address: City: State: Zip: Home phone: Cell phone: Work phone: address: Preferred method of contact: What is your estimated current height: weight: Primary Care Provider (PCP) Name, address & phone number: What is the main reason for your visit to the Breast Cancer Prevention Center? Racial Categories (may select more than one): Demographic Information American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White (includes Hispanic or Latino) Ethnic Categories: Hispanic or Latino Not Hispanic or Latino Ashkenazi Jewish Descent: Yes No Unknown

2 What is your current marital status? Social History Single Married Partnered Divorced Widowed Education level completed: High School / GED Some college or an associate s degree College Graduate / professional school Vocational / technical school beyond high school Current occupation: What is your current employment status? (Check the one that most applies to you) Employed full-time Employed part-time Retired Homemaker On medical leave Unemployed and/or seeking work Disabled Other: Are you a student? No Yes If yes, are you: Full time Part-time Please check the best approximate income level range of your household: Less than $20,000 $20,000 to $40,000 $40,000-$60,000 $60,000 or over Lifestyle Have you ever smoked? No, never Yes, currently Yes, but only in the past If yes, on average, how many cigarettes do you or did you smoke per day? At what age did you START smoking? If you quit, at what age did you STOP smoking? Total number of years as a smoker? years old years old years Have you ever or do you currently drink alcohol? No, never Yes, currently Yes, but only in the past If yes, currently or in the past, how many alcoholic beverages (beer, wine, mixed drinks, etc.) do you consume per month? (1 drink is equal to 1 mixed drink, 1 beer, or 1 glass of wine) Average # of drinks per month: 2

3 Do you exercise regularly? No Yes Please indicate the total average # of hours per week you exercise: What is the typical type of exercise that you do regularly? Breast Health Do you have mammograms performed? Yearly Infrequently Never If you have had a mammogram, what was the date of your last mammogram: / / If you do not have mammograms performed yearly, check all reasons that apply to why you do not generally receive an annual mammogram: Not covered by insurance Covered by insurance, but only after deductible met Covered by insurance, but only every other year Covered by insurance, but only for women over 50 I or my children have to take time off work Too far to go to obtain a mammogram Have not thought about it or it has not been a priority My physician does not recommend one I think I am too young for screening by mammogram I am afraid of the possible results I think the x-rays from the mammogram may cause cancer I do not think I am at risk of developing breast cancer I am afraid the mammogram will be painful Have you ever had a breast sonogram? No Yes If yes, what was the date and result of your last sonogram? Have you ever had a breast MRI? No Yes If yes, what was the date and results of your last MRI: Do you have breast implants? No Yes If yes, date of surgery: / / Do you have any problems with your implants? No Yes If yes, describe: Have you undergone a breast reduction? No Yes If yes, date of surgery / / 3

4 Have you had any prior breast surgery, including biopsies, lumpectomy, mastectomy (prophylactic or for cancer)? No Yes If yes, complete information below for each event. Please ensure that corresponding pathology reports have been received by our office. Start with the most recent procedure, if more than 4, please list on a separate page (check if page attached ): Indicate Right or left breast R L Procedure (core biopsy, excisional biopsy, etc.) Hospital and City where performed Approximate date (mm/yyyy) Results of pathology report R R R L L L Have you ever been diagnosed with breast cancer? No Yes If yes, did you receive other types of treatment for your breast cancer and what were the approximate dates? Radiation Therapy Type of treatment Check all that apply Date of Treatment (mm/yyyy) Duration of Treatment Chemotherapy Antihormonal Therapy (i.e Nolvadex (tamoxifen), Evista (raloxifene), femara (letrozole), Arimidex (anasterozole) Gynecological History I am (check one): Premenopausal Peri-menopausal Postmenopausal (age: ) If postmenopausal: Natural (Uterus and ovaries intact, no menstrual period last 12 months) Partial Surgical (Uterus removed, one or both ovaries intact) Partial Surgical (Both ovaries removed, uterus intact) Complete Surgical (Uterus and both ovaries removed) 4

5 Are you currently having regular menstrual cycles? Yes No If yes, are your periods regular (every days)? Yes No What is the date of your last menstrual cycle (even if you are postmenopausal)? / / How old were you when you had your first period? years old Reproductive History Have you ever been pregnant? Yes No If yes, how many pregnancies have you had? Have you ever had a miscarriage? Yes No If yes, how many miscarriages have you had? How many live births have you had? How old were you when you had your first child? years old Have you ever breast fed? Yes No If yes, for how many months? Have you ever undergone fertility treatments? No Yes total # of months: General Medical Information Please list other previous surgical procedures, hospitalizations, injuries, or other prior medical events (other than breast procedures) If additional space is required, please attach an additional page (check if page attached ). Event Date(mm/yyyy) Reason for event 5

6 Allergies Do you have any allergies? (Include medication, environmental, chemical, latex, betadine) No Yes (please indicate below) What are you allergic to? What your reaction is: Medications List all current medications you are taking. If additional space is required, please attach an additional page (check if page attached ). Medication Dose Frequency (how often you take the medicine) Date started (mm/yyyyy) (Office use only) Class of Drug Hormone History Have you used hormones in the past? No Yes If yes, complete information below - all current hormone use should be indicated in the medication table. Hormone Therapy previously taken Estrogen plus progesterone therapy Estrogen only replacement therapy Birth control pills No Yes No Yes No Yes If yes, total # of years taken If yes, estimate month/year most recently STOPPED taking. 6

7 Bone Health Have you had a bone mineral density? No Yes If yes, date / / Do you have low bone mineral density (osteoporosis/osteopenia)? No Yes Unknown Do you have a family history of osteoporosis? No Yes If yes, list relatives: Have you taken calcium supplements: No Yes If yes, Dose How long? yrs Have you taken corticosteroids for an extended period of time? (i.e. prednisone, decadron)? No Yes If yes, for what reason? Have you ever had your Vitamin D level drawn? No Yes If yes: Date / / Result: Heart Health Have you ever had a fasting lipid profile: No Yes If yes, date / / If yes, normal results: No Yes Has anyone in your family had heart disease (hypertension, coronary artery disease, stroke, heart attack, etc.) diagnosed under age 60? No Yes If yes, list relatives Colon Cancer Risk Have you undergone a colonoscopy or flexible sigmoidoscopy: Yes No If yes: Date / / If yes, normal results: Yes No Were any polyps removed? Yes No If polyps removed, what were the results? 7

8 Review of Systems Do you presently have any problems or symptoms in the following areas? If yes, please give an explanation. Circle One: Patient Comments: Menopausal Symptoms (please state whether mild, moderate, or severe) Hot flashes Y N Vaginal dryness Y N Memory problems Y N Mood swings/irritability Y N Decreased sex drive Y N Hair loss/skin change Y N Weight Gain Y N Sleep disturbances/night sweats Y N Constitutional Good general health past year Y N Recent weight changes (more than 10 lbs.) Y N Recurrent fevers, chills, sweats Y N Fatigue Y N Stress Y N Pain Y N Eyes Wear glasses/contact lenses Y N Blurred or double vision Y N Change in vision Y N Glaucoma Y N Difficulty hearing Y N 8

9 For Office Use Only: Medical Record #: HRBC#: Ear/Nose/Mouth/Throat Ringing in the ears Y N Recent nose bleeds Y N Chronic sinus problems Y N Mouth sores Y N Bleeding gums Y N Frequent sore throats Y N Voice changes Y N Hoarseness Y N Respiratory Asthma or wheezing Y N Breathing problems Y N Chronic cough Y N Cardiovascular Murmur Y N Chest pain or angina Y N Shortness of breath Y N Palpitations Y N Swelling of feet, ankles or hands Y N Blood clots (leg or lung) Y N Varicose veins Y N High blood pressure Y N Prior deep vein thrombosis (DVT) Y N High Cholesterol Y N Coronary artery disease (clogged arteries) Y N Prior heart attack Y N Prior stroke Y N

10 Gastrointestinal Change in appetite Y N Severe heartburn Y N Increase or Decrease in weight Y N Frequent nausea/vomiting Y N Frequent diarrhea Y N Constipation/painful bowel movement Y N Black or bloody stools Y N Rectal bleeding Y N Rectal/Colon Polyps Y N Ulcerative colitis Y N Abdominal pain Y N Bleeding ulcers Y N Genitourinary Blood in the urine Y N Burning with urination Y N Vaginal dryness or painful intercourse Y N Sexually transmitted disease Y N Change in sexual function or interest Y N Gynecologic History of abnormal Pap smear Y N Cysts on the ovaries Y N Fibroids in the uterus Y N Endometriosis Y N Abnormal uterine bleeding Y N Painful periods Y N 10

11 Integumentary (skin & breasts) Birth marks Y N Recurrent rashes Y N Changing moles Y N Skin cancer or melanoma Y N Non-healing wounds Y N Breast pain or lump Y N Fibrocystic breasts Y N Nipple discharge Y N Change in hair (loss or increase) Y N Nervous System Nervousness Y N Depression Y N Problems sleeping Y N Anxiety Y N Headaches Y N Migraine headaches Y N Change in memory/concentration Y N Family history of Alzheimer s Disease Y N Numbness or tingling sensations Y N Weakness or paralysis Y N Musculoskeletal Joint stiffness or pain Y N Muscle pain or cramping Y N Weakness of muscles or joints Y N Back pain Y N Difficulty walking Y N 11

12 Endocrine Heat or cold intolerance Y N Excess thirst or urination Y N Diabetes Y N Arthritis (osteo, rheumatoid) Y N Over or under active thyroid Y N Allergic/Immunologic Low resistance to infection Y N Frequent cold or flu Y N Environmental allergies Y N Latex Y N Betadine Y N Epinephrine Y N Hematologic/Lymphatic Easy bruising Y N Frequent/difficulty stopping bleeding Y N Enlarged lymph nodes Y N 12

13 Genetic Testing Have you been tested for BRCA1 or BRCA 2 mutations? Yes No If yes, was the test positive for a mutation? Yes, BRCA 1 Yes, BRCA 2 No Have any family members been tested for BRCA1 or BRCA2 mutations? Yes No If so, indicate the following: Relationship (i.e., mother, cousin, etc): Are they on your mom s side or dad s side of the family? Did they test positive for a mutation? Yes No If so, was it a BRCA1 or BRCA2 mutation? Family History Please indicate all women in family and their ages regardless of whether or not they have been diagnosed with cancer. If they have had cancer, please include their age at diagnosis. If they are deceased, please include their age at passing. If you do not know exact ages, please approximate. What is your mother s current age(if living)? Has she ever been diagnosed with breast cancer? Yes (age at diagnoses: ) No Has she ever been diagnosed with ovarian cancer? Yes (age at diagnoses: ) No Is she still living? Yes No (what was her age at passing? ) Please correlate the numbers when indicating which family member was diagnosed with cancer. For example: If you have 2 sisters, and the sister listed next to number 1 was diagnosed with cancer; under age of diagnosis, write her age at diagnosis in the number 1 spot. How many sisters do you have? What are their ages? 1: 2: 3: 4: 5: 6: 7: Have any of them been diagnosed with ovarian cancer? Yes No Are all of your sisters still living? Yes No If no, age at passing: 1: 2: 3: 4: 5: 6: 7: 13

14 What is your paternal grandmother s current age (if living)? Has she ever been diagnosed with breast cancer? Yes (age at diagnoses: ) No Has she ever been diagnosed with ovarian cancer? Yes (age at diagnoses: ) No Is she still living? Yes No (what was her age at passing? ) What is your maternal grandmother s current age (if living)? Has she ever been diagnosed with breast cancer? Yes (age at diagnoses: ) No Has she ever been diagnosed with ovarian cancer? Yes (age at diagnoses: ) No Is she still living? Yes No (what was her age at passing? ) How many sisters does your dad have? What are their ages? 1: 2: 3: 4: 5: 6: 7: Have any of them been diagnosed with ovarian cancer? Yes No Are all of your dad s sisters still living? Yes No If no, age at passing: 1: 2: 3: 4: 5: 6: 7: How many sisters does your mom have? What are their ages? 1: 2: 3: 4: 5: 6: 7: Have any of them been diagnosed with ovarian cancer? Yes No Are all of your mom s sisters still living? Yes No If no, age at passing: 1: 2: 3: 4: 5: 6: 7: 14

15 How many daughters do you have? What are their ages? 1: 2: 3: 4: 5: 6: 7: Have any of them been diagnosed with ovarian cancer? Yes No Are all of your daughters still living? Yes No If no, age at passing: 1: 2: 3: 4: 5: 6: 7: How many half-sisters do you have on your mom s side? What are their ages? 1: 2: 3: 4: 5: 6: 7: Are all of your half-sisters (maternal) still living? Yes No If no, age at passing: 1: 2: 3: 4: 5: 6: 7: How many half-sisters do you have on your dad s side? What are their ages? 1: 2: 3: 4: 5: 6: 7: Are all of your half-sisters (paternal) still living? Yes No If no, age at passing: 1: 2: 3: 4: 5: 6: 7: 15

16 The following is only needed if any of your 1 st cousins or nieces have been diagnosed with breast cancer: How many female 1 st cousins do you have on your mom s side? What are their ages? 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13: 14: Age at diagnosis: 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13: 14: Which of your mom s brothers/sisters are the affected cousins from? Are all of your maternal cousins still living? Yes No If no, age at passing: 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13: 14: How many female 1 st cousins do you have on your dad s side? What are their ages? 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13: 14: Age at diagnosis: 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13: 14: Which of your dad s brothers/sisters are the affected cousins from? Are all of your paternal cousins still living? Yes No If no, age at passing: 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13: 14: 16

17 How many nieces do you have? What are their ages? 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13: 14: Age at diagnosis: 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13: 14: Which of your sister(s), half-sister(s) or brother(s) are the affected nieces from? Sister (1-7): Brother: Maternal half-sister (1-7): Paternal half-sister (1-7): Are all of your nieces still living? Yes No If no, age at passing: 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13: 14: You may list any other family members who have been diagnosed with cancer here. Please indicate their relation to you, and their age at diagnosis. 17