Patient Registration Date:

Transcription

1 Appt Date: Time: Patient Registration Date: I prefer to be called: Last First MI Date of Birth: Social Security Number: Address: City: State: Zip: Home # ( ) Cell # ( ) Work# ( ) Which number(s) may we use? Home Cell Work May we leave a message? Yes No Address: Single Married Widowed Separated Divorced Number of Dependents: Employed Retired Disabled Occupation: Employer: Have you served in the military No Yes Where When Spouse or Significant Other s Emergency Contact: Phone: Relationship: Race: Caucasian American Indian Asian Ethnicity: Hispanic Non Hispanic African American Na ve Hawaiian Alaskan Unknown Other Decline to Answer Do you have a Legal Guardian? Yes No If yes, please provide Guardians Phone Number: Do you have an Advanced Directive? Yes No If no, are you interested in information? Yes No Preferred Main Language: English Spanish Arabic Other Whom may we thank for referring you? Doctor Information Family/Primary Physician: Referring Physician: Additional Physicians: Phone: Phone: Phone: Primary Insurance Name of Insured DOB SSN# Relationship to Patient: Self Spouse Dependent Other Insurance Company Grp # ID# Secondary Insurance Name of Insured DOB SSN# Relationship to Patient: Self Spouse Dependent Other Insurance Company Grp # ID# Page 1 of 9

2 New Patient History Briefly describe the reason for your visit today: Cancer History Type of your cancer: Date of Diagnosis: If you have had previous treatment, please include type of treatment below: Treatment with surgery: Yes No When & Where: Radiation Therapy: Yes No When & Where: Chemotherapy: Yes No When & Where: Medical History Please check if you have had any of the following medical conditions Anemia Gallbladder Disease Pacemaker / Defibrillator Arthritis Acid Reflux Anxiety Asthma Glaucoma Seizures Bleeding Disorders Heart Disease Stomach Ulcers Breast Disease Hepatitis Stroke Cancer High Blood Pressure Thyroid Disease COPD/Emphysema High Cholesterol Tuberculosis Depression HIV/AIDS Heart Attack Diabetes Kidney Disease Lupus/Scleroderma Additional Comments: Surgical History Please list all surgeries, major diseases, illnesses, or conditions for which you have been hospitalized: Surgeries or hospitalizations Date Where Page 2 of 9

3 Pain Where does it hurt? Tell us what is your pain rating at its worst? When did the pain start? Is the pain: constant on and off dull sharp burning pressure (please circle) What relieves the pain? How often do you have to take pain medication? Pain rating after taking medication? Genetic Risk Assessment This is a screening tool for cancers that run in families. Please consider these family members when completing the form: Mother/Father/Sister/Brother/Children/Grandparent Aunt/Uncle/Niece/Nephew/Cousin/Great Grandparent Have you or any of your relatives been tested for hereditary cancer in the past? YES NO Have you ever been diagnosed with cancer? What site: Age: TYPE OF CANCER YOUR RELATIONSHIP TO FAMILY MEMBER W/ CANCER Self, sibling, AGE AT child, parent MOTHER'S SIDE FATHER'S SIDE DIAGNOSIS EXAMPLE: Colon Sister 42 EXAMPLE: Breast Aunt 54 Page 3 of 9

4 Current Medication List List all medications you are taking, including vitamins, nonprescription drugs, and herbal supplements. Bring all Medications to your first appointment Drug Amount/Dose Frequency Retail Pharmacy Phone# ( ) Mail Order Pharmacy Phone# ( ) Do you have prescription coverage? Yes No Do you have a prescription co pay? Yes No Amount $ Authorization to electronically submit prescription(s) directly to Pharmacy: (Initials) Allergy Information Latex Allergy Yes No Iodine Allergy Yes No OTHER ALLERGY INFORMATION REACTION Immunization Vaccine Date Received: From Whom: Vaccine Date Received: From Whom: Page 4 of 9

5 Social History Religious Belief Catholic Jewish Protestant Muslim Other: Decline to Answer Education Grade School High School College Other: Have you Asbestos Chronic Fumes Chronic Dust Radiation Toxic Chemicals been exposed to: Others: Preferred Language English Spanish Arabic Other Alcohol Use How many alcoholic beverages do you drink per week: Smoking Status Never smoked Current Smoker How many years have you smoked? How many cigarettes do you smoke a day? Quit When did you quit? How many years did you smoke? How many cigarettes did you smoke per day? Cigarettes Marijuana Cigars or pipes Chewing tobacco Hookah Other Use of recreational substances? Please specify: Have you been exposed to second hand smoke? Do you need a translator? If yes, preferred language: Do you have transportation to medical appointments? Do you have family or friends to help during treatment? Do you have emotional support from family or friends? Do you have someone living with you? If yes, Name: Safety Questions: Do you feel safe in your environment? Have you been threatened/harmed? Threatened/Harmed emotionally? Threatened/harmed financially? Threatened/harmed physically? Threatened/harmed sexually? Have you had a fall in the last six months? Do you need help with standing/walking? Do you have periods of forgetfulness? Have you used an assistive device? If so, please check: cane crutches stretcher walker wheelchair Yes No Page 5 of 9

6 Recent Medical History Check all of the boxes that apply to your health during the last six months: General symptoms Loss of appetite Yes No Unexplained tiredness Yes No Prolonged fever Yes No Night sweats Yes No Weight loss Yes No Weight gain Yes No Eyes Blurred vision Yes No Double vision Yes No Eye Pain Yes No Wears Glasses/Contacts Yes No Ears/Nose/Throat Pain/Difficulty swallowing Yes No Ear Pain Yes No Frequent nose bleeds Yes No Hearing loss Yes No Dry Mouth Yes No Persistent sore throat Yes No Persistent hoarse voice Yes No Oral Bleeding Yes No Sinus Problems Yes No Sputum production Yes No Sores on lips or mouth Yes No Altered Taste Yes No Buzzing or ringing in ears Yes No Do you wear hearing aids Yes No Skin Hair loss Yes No Bruise easily Yes No Dry skin Yes No Sensitivity to the sun Yes No Persistent/recurring rash Yes No Breast Breast Masses Yes No Nipple Discharge Yes No Nipple inversion Yes No Pain Yes No Respiratory/Cardiovascular Irregular/rapid heartbeat Yes No Chest pain or angina Yes No Shortness of breath Yes No Palpitations Yes No Ankle/leg swelling Yes No Cough that persists Yes No Painful/difficulty breathing Yes No Cough up blood Yes No Page 6 of 9 Wheezing Yes No Use supplemental oxygen Yes No Gastrointestinal Stomach pain or cramping Yes No Change in bowel habits Yes No Constipation Yes No Diarrhea Yes No Heartburn Yes No Bloody vomit Yes No Hemorrhoids Yes No Rectal bleeding Yes No Nausea Yes No Vomiting Yes No Feeling of fullness Yes No Urinary Burning/painful urination Yes No Urinating frequently Yes No Blood in urine Yes No Urinary incontinence Yes No Waking to urinate at night Yes No Sensation of urgency Yes No Trouble starting stream Yes No Weak urinary stream Yes No Musculoskeletal Arthritis Yes No Bone pain Yes No Painful or swollen joints Yes No Muscle weakness Yes No Limited range of motion Yes No Neurological Dizzy spells Yes No Loss of balance Yes No Frequent headaches Yes No Insomnia Yes No Memory loss Yes No Numbness or tingling Yes No Loss of strength Yes No Seizures or tremors Yes No Changes in speech Yes No Psychological Feeling depressed Yes No Feeling anxious Yes No Mood swings Yes No

7 Female Gynecologic History Breast History Breast cyst, or lump Yes No Right / Left / Both Breast pain or tenderness Yes No Right / Left / Both Nipple discharge Yes No Right / Left / Both Previous breast biopsies Yes No Right / Left / Both Previous history of Breast Cancer: Date of last mammogram: Where performed? Date of last Pap smear? Where performed? Menstrual History Age when menstruation began? Are you still having monthly periods? Yes No Is your menstruation slight, moderate, heavy, or irregular? Are you presently using an IUD or birth control pills? Date of your last menstrual cycle: Is there any possibility you could be pregnant at this time? Yes No Please note that patients who have not had a tubal ligation, hysterectomy, or are post menopausal may require additional lab work prior to starting any radiation therapy. Menopause If you are no longer having a menstrual cycle, at what age did your monthly periods stop? Did your menopause occur as a result of: Natural Surgery Following chemotherapy? Do you experience hot flashes? Yes No Any previous history of hormone use Contraceptive Hormone use: No If yes, for how many years: Post Menopause Hormones: No If yes, for how many years: Pregnancies Number of pregnancies: Number of children born alive: What was your age at your first pregnancy? Page 7 of 9

8 Date: Authorized Patient Communication List Patient or authorized person: I authorize any physician, hospital, or medical care facility to provide all information regarding my medical history and treatment to the Karmanos Cancer Institute. Photocopies of this form may be considered to be as valid as the original. (Optional) Patient or authorized person: I authorize Karmanos Cancer Institute to discuss my medical condition and/or release medical information the following people (i.e. family members): Name Relationship DOB Phone Name Relationship DOB Phone Name Relationship DOB Phone Name Relationship DOB Phone If our office is unable to reach you personally, may we leave protected health information such as test results, appointment dates or returned messages by the following forms of communication? Please check one answer for EACH option With a Family Member listed above: Yes No Home Answering Machine: Yes No Cellular Phone Voic Yes No Mail to Home Address: Yes No Signature of Patient/ Authorized Individual Date & Time Page 8 of 9 updated: 03/20/17

9 Financial Statement 1. It is the patient s responsibility to know and understand the terms of their insurance policy, this includes but is not limited to In/Out of network costs, deductibles, coinsurance or co pays. Our staff will verify your insurance coverage. It is the patient s responsibility to supply all current insurance cards. C0 PAYS AND DEDUCTIBLES ARE DUE AT THE TIME OF SERVICE. For those patients with cancer who do not have an insurance plan, financial services and patient assistance programs are available on a local, regional and national basis. These services include, but are not limited to, Medicaid and drug assistance programs sponsored by most major pharmaceutical company. Patients who are underinsured should contact our Patient Billing Department immediately for assistance on how to participate or enroll in these services. Your billing will consist of two components, a facility charge and a professional charge. Facility charges will be submitted to your insurance carrier for consideration and may include a co pay. Professional charges are billed separately. You will receive a statement following submission to your insurance carrier. Pathologists, radiologists, laboratory and other specialists are required to submit separate bills. If you have any questions regarding the bills, please contact the providers at the telephone number printed on the statement. I have read, understand and agree to the above financial policy Signature of patient or responsible patient Date Time 2. Patient or authorized person: I authorize any physician, hospital or medical care facility to provide all information regarding my medical history and treatment to my Karmanos Physicians and Care Team. Photocopies of this form will be considered to be as valid as the original. Signature of patient or responsible patient Date Time Page 9 of 9 updated: 03/20/17