Divisio n of Gynecologic Oncology
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- Harold Beasley
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1 Divisio n of Gynecologic Oncology Richard G. Moore, MD, FACS, FACOG, Division Chief Cynthia Angel, MD, FACOG Brent DuBeshter, MD, FACOG Cici Lui, MD, FACOG Sajeena Thomas, MD, FACOG Rachael Turner, MD, PhD Negar Khazan, PhD Kyu Kwang Kim, PhD Rakesh Singh, PhD Diana Bailey, MS, CGC Lauren Mahon, NP Janelle Hennard, NP Sarah Rossi, NP Kim Altobelli, RN, OCN Karen Kugel, BSN, RN, OCN Gina Smith-Donke, BSN, RN, OCN Carolyn Jane Walsh, BSN, RN Melissa Buffin, BSN, RN, OCN Dawn Torpey, BSN, RN Clinical Research Group: Laura Mitchell Erika Bronk Mary Sears Barbara Kavinsky Office Man ager: Sherri Krohn University of Rochester Medical Center Wilmot Cancer Institute 125 Lattimore Road, Suite 258 Rochester, NY Phone: (585) Fax: (585) Patient Name: DOB: _ Date: Welcome to our practice. Please answer the following questions in the appropriate spaces below. Use a question mark (?) if you are unsure of an answer. Please answer all questions as completely as possible. Please complete both front and back of each page. What is your understanding of why you are here? Allergies: Yes_ No_ Do you know of anything you are allergic to or gives you a rash? If so, please list: Drug/Food Reaction Medications: Yes_ No_ Do you take any medications regularly? Please include prescriptions as well as over the counter medications, vitamins, and supplements. Medications Dose How often _ Review of Systems: Are you currently experiencing any of the following? Yes_ No_ Pain or incontinence with urination Yes_ No_ Constipation or Diarrhea Yes_ No_ Weight gain or weight loss Yes_ No_ Swelling of hands or feet Yes_ No_ Problems with eyesight or hearing Yes_ No_ Pain Location_: Please rate on a scale from 1-10 with 10 being the worst pain you have experienced: 1 of 4
2 Screening: Yes_ No_ Have you had a mammogram? When? Results? _ Yes_ No_ Have you had a colonoscopy? When? Results? _ Yes_ No_ Have you had a pap smear? When? Results? _ Surgical History: Yes_ No_ Have you had any surgeries or hospitalizations? Please list with approximate year. Gynecologic History: Yes_ No_ Have you ever been pregnant? Number of pregnancies? _ Number of births? _ Yes_ No_ Are you currently sexually active? Method of birth control? Yes_ No_ Have you used birth control pills or hormones? For how long? Yes_ No_ Have you gone through menopause? Date of last menstrual period? Social History: Yes_ No_ Do you drink alcohol? How often? _ Yes_ No_ Do you smoke? Daily Occasionally Former smoker Yes_ No_ Do you use recreational drugs? Marital Status: Married Single _Widowed Divorced_ Life Partner Occupation: Medical/ Family History: Please check Self if you have had one of the following problems, check Family and indicate which member of your family has/had this condition. Condition: None Self Family (please indicate relation of relative) Arthritis Alzheimer s disease Asthma Blood clots Diabetes Hypertension Heart disease HIV Hepatitis Kidney disease Stroke Other 2 of 4
3 Cancer History: Yes_ No_ Do you have a history of cancer? If yes, please complete the table below for your past cancer, radiation treatment, or chemotherapy that you may have had. Past cancer type Age of first Diagnosis Did you receive chemotherapy? Did you have surgery? Did you have radiation therapy? Did you have another treatment type? Yes Age No Yes Age No Yes Age No Yes (List Type) Age No Yes_ No_ Do you have any family history of cancer? If yes please complete the table below for family history of cancer. Please provider as much detail as you can about any additional relatives who have had cancer on your paternal (father s side of the family) and maternal (mother s side of the family) relatives. Remember to include those who are no longer living. Mother Father Sons Daughters PATERNAL (Father s side) Cousins Grandsons Granddaughters Grandfather Grandmother Uncles Aunts Half-brothers Half-sisters Other relatives MATERNAL (Mother s side) Cousins Grandsons Granddaughters Grandfather Grandmother Uncles Aunts Half-brothers Half-sisters Other relatives Been diagnosed with cancer? If YES: Yes No Type of Cancer Age of onset 3 of 4
4 Yes_ No_ Have you or anyone in your family had genetic testing for a hereditary cancer syndrome? Advanced Directives: Yes_ No_ Have you completed a Health care proxy or Advanced directive? Yes_ No_ If not would you like information regarding appointing a Health care proxy? Please list other healthcare providers who should receive information regarding your care: To the best of my knowledge, the information provided on this form is accurate and complete. Signature of Patient or Representative: Date: Date reviewed: by: 4 of 4
5 Divisio n of Gynecologic Oncology Richard G. Moore, MD, FACS, FACOG, Division Chief Cynthia Angel, MD, FACOG Brent DuBeshter, MD, FACOG Cici Lui, MD, FACOG Sajeena Thomas, MD, FACOG Rachael Turner, MD, PhD Negar Khazan, PhD Kyu Kwang Kim, PhD Rakesh Singh, PhD Diana Bailey, MS, CGC Lauren Mahon, NP Janelle Hennard, NP Sarah Rossi, NP Kim Altobelli, RN, OCN Karen Kugel, BSN, RN, OCN Gina Smith-Donke, BSN, RN, OCN Carolyn Jane Walsh, BSN, RN Melissa Buffin, BSN, RN, OCN Dawn Torpey, BSN, RN Clinical Research Group: Laura Mitchell Erika Bronk Mary Sears Barbara Kavinsky Office Man ager: Sherri Krohn University of Rochester Medical Center Wilmot Cancer Institute 125 Lattimore Road, Suite 258 Rochester, NY Phone: (585) Fax: (585) AMBULATORY CARE INVOLVEMENT IN CARE DISCUSSION FORM (Reference HIPAA Policy 0P23.2) Patient Name: Date: _ Gynecologic Oncology may discuss protected health information, including lab/test results with the following personal relatives and friends: Name Relationship Phone Number NEXT OF KIN INFORMATION Name: Relationship: Address: _ City: State: _ Zip Code: Phone: Alternate Number: COMMUNICATION REQUESTS: Phone me using the following (#) Y N May phone at work (#) May leave messages on voice mail or answering machine? May send message via MyChart? Would you like to list an ? If yes please list below: This will remain in effect until notified differently by the patient. Patient Signature: Date:
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
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Tel: (312) 694-7337 Women s Integrated Fax: (312) 695-0156 Pelvic Health Program 1.0: Basic Information Date of Birth: / / Age: Home Address: Preferred Language: English Spanish Other: Email address: Preferred
Other doctors to receive copies of records : Chief complaint / history of present illness (Describe why you have been referred here):
Patient Name: Date: Age: Date of Birth: Preferred Name: Preferred Language: Address: City: State: Zip: Phone: Cell Phone: Preferred Phone: Emergency Contact: Relationship: Email: If you would like to opt
Weight Loss Surgery Program Application
Weight Loss Surgery Shaded area for office use only SELF LAST NAME FIRST MI MAIDEN CITY STATE ZIP SOCIAL SECURITY NUMBER DATE OF BIRTH AGE MALE FEMALE MARRIED DIVORCED WIDOWED SEPARATED NEVER MARRIED RACE:
Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI P (734) F (734) New Patient Intake Form
Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI 48103 P (734) 547-3990 F (734) 547-3890 New Patient Intake Form Personal Information Name Age Sex Female Male Gender Identify
Adult Health History
Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit
BARIATRIC PROGRAM PREVIOUS BARIATRIC SURGERY HEALTH QUESTIONNAIRE (PLEASE PRINT CLEARLY)
BARIATRIC PROGRAM PERSONAL INFORMATION PREVIOUS BARIATRIC SURGERY HEALTH QUESTIONNAIRE (PLEASE PRINT CLEARLY) Name: Date: Sponsor s SSN# - - Date of Birth: Age: Mailing Address: City: State: Zip: Mobile
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire Donor s Name: Today s Date: Social Security #: Date of Birth Age Sex Address: Telephone #: (home) (work)
Health Questionnaire
Patient Name Date of Birth Thank you for choosing Southern Cancer Center for your care. To help us best prepare for your appointment, please complete this form and bring it to your appointment. If you