University Gynecologic Oncology Associates
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- Piers Gordon
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1 University Gynecologic Oncology Associates Medical History Form Date: Name: Date of Birth: / / GYNE HISTORY Age of first period? If you no longer have periods, at what age did they stop? Are you pregnant or breast feeding? Yes No Please list: Total # of Pregnancies? Abortions? Miscarriages? Do you plan to get pregnant within the next year? Yes No Age at Menopause Hormone Replacement Therapy use? Yes No If yes, for how long? Any history of STD? Yes No If yes, What When Fibroids? Yes No Endometriosis? Yes No Are you using any birth control? Yes No If yes, what type? Date of last pap smear result Any history of abnormal pap smears? Yes No If yes, date result Date of last mammogram, result Date of last Colonoscopy Period Cycle (Days) Period Duration (Days) Period Pattern Regular Irregular Menstrual Flow Light Moderate Heavy Dysmenorrhea (painful periods) None Mild Moderate Severe Dysmenorrhea (symptoms of painful periods) Cramping Throbbing Nausea Diarrhea Headache CANCER HISTORY (Check all current or past cancers) Bladder Cancer Bone Cancer Brain Cancer Breast Cancer Cervical Cancer Colon Cancer Esophageal Cancer Fallopian Tube Leukemia Lung Cancer Pancreatic Cancer Primary Peritoneal Cancer Other Cancer Ovarian Cancer Skin Cancer Small Intestine Cancer Gastric Cancer Uterine Cancer Vaginal Cancer Vulvar Cancer None 1
2 MEDICAL HISTORY (Check all current or past problems) Abnormal Uterine Bleeding Amenorrhea (no menstrual cycles) Anemia (low blood count) Anxiety Arthritis Asthma Back Pain Blood Transfusion BRCA Gene (breast cancer gene) Congestive Heart Failure Clotting Disorder Chronic Obstructive (bleeding problems) Pulmonary Disease Demential/Alzheimers Depression Diabetes Mellitus DVT Dysmenorrhea Dyspareunia (blood clots) (painful periods) (painful intercourse) Emphysema Endometriosis Fibroids Genital Warts Gastro Esophageal Reflux Disease Heart Murmur Hepatitis B Hepatitis C Hernia Herpes HIV/AIDS HNPPC-Lynch Syndrome (increase genetic risk for colon or endometrial cancer) Hypertension Irregular Menses Kidney Disease (high blood pressure) Meningitis Myocardial Infarction Nerve/Muscle Disease (heart attack) Pelvic Inflammatory Disease Osteoporosis Pulmonary Embolism (blood clot in the lungs) Ovarian Mass Seizures Sickle Cell Anemia Stroke Thyroid Disease Tuberculosis (TB) Ulcers Uterine Anomalies Urinary Incontinence (misshaped uterus) (leaky bladder) None SURGICAL HISTORY Adnexal Cystectomy Appendectomy Back Surgery (removal of a portion of the ovary) (removal of the appendix) Bilateral Salpingo-Oophorectomy Cholecystectomy Cold Knife Conization (removal of tubes and ovaries) (removal of gallbladder) (removal of portion of the cervix) Colon Surgery Cryosurgery Dilation & Curettage (D&C) (freezing of the cervix) Heart Surgery- type: Hysteroscopy (looking inside the uterus with a camera) Hysterectomy (removal of the uterus) Loop Electrosurgical Excision (LEEP procedure) Salpingectomy Thyroid Surgery Tonsillectomy (removal of tonsils) (removal of the fallopian tube) Tubal Ligation (tubes tied) Unilateral Salpingo Oophorectomy (removal of tube and ovary on one side only) 2
3 TOBACCO USE HISTORY Tobacco Use? Yes No Smokeless Tobacco Status Yes No Quit Date SOCIAL HISTORY- ALCOHOL Alcohol Use Never Currently Former Frequency of Use Rarely Daily Weekly Monthly Years Quit Date (approx) SOCIAL HISTORY- RECREATIONAL DRUGS Recreational Drug Use Never Currently Former Drugs Used Frequency of Use Rarely Daily Weekly Monthly Last Use (approx) Quit Date (approx) SOCIAL HISTORY- LIVING ARRANGEMENTS Living Arrangement Alone With Family With Other(s) Single Room Occupant Group Home Half-way House Skilled Nursing Facility Assisted Living Homeless Other Able to perform Activities of Daily Living Yes No FAMILY HISTORY (For any past or current illness in your family write the relation of the family member) Cancer type: Family Member(s) Other Illness Family Member(s) ALLERGIES AND ADVERSE REACTIONS (List any substances that have caused a bad reaction, and describe the reaction. Include prescription or non-prescription medicines, foods, plants or other materials.) Substance Reaction Substance Reaction 3
4 MEDICATIONS (List any medications you use, prescription or non-prescription, including the dose and how often you take it. Please include all types of medicine, including creams and eye drops.) Medication Dose and Frequency Medication Dose and Frequency Are you taking or using anything else for your health or to treat symptoms (such as vitamins, herbs or weight loss products? Please list them: Please circle the number that best describes the level of each symptom listed below you may be currently experiencing. Symptom None A little Quite a bit A lot Nausea/Vomiting Fatigue Pain (where? ) Change in vision Change in hearing Chest Pain Palpitation Shortness of breath Cough Diarrhea Constipation Blood in bowel movements Pain with urination Blood in urine Lost control of urine Abdominal pain Abdominal bloating Skin rash Numbness/Tingling of hands or feet Headaches Depression/Mood Changes Vaginal bleeding Easy bruising/bleeding Hot flashes All other systems negative 4
5 ADVANCE DIRECTIVES Do you have a Living Will (instructions about how much medical care you want given if you get very sick)? Yes No Don t know Do you have a Power of Attorney for health care (instructions about who you want to make medical decisions for you if you are not able to make them)? Yes No Don t know Would you like more information about a Living Will or a Power of Attorney? Yes No R- 11/03/11 5
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Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
Austin Fertility and Reproductive Medicine
NEW PATIENT QUESTIONNAIRE 1. GENERAL INFORMATION Name: Age Date of Birth Occupation Partner s Name (if applicable): Partner s Date of Birth Partner s Occupation Age Who referred you/how did you hear about
Marcelo Garzon HOM.DSHomMed.Bsc. (Please be certain that all in take forms are completed and returned on time)
Marcelo Garzon HOM.DSHomMed.Bsc. www.sagehomeopathy.ca (Please be certain that all in take forms are completed and returned on time) NAME: Personal Health History DATE: OHIP # D.O.B : AGE: PHONE: MAY WE
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages