PATIENT HEALTH HISTORY
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- Jack Cox
- 5 years ago
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1 DATE: DEMOGRAPHICS Name: Date of Birth: Ethnicity (optional): Hispanic or Latino ot Hispanic or Latino Race (optional): White Black or African American Asian Indian Japanese ative Hawaiian Chinese Guamanian or Chamorro Korean Filipino Vietnamese Samoan Other Asian (Please state): Other Race: Sex: Male Female PREFERRED LANGUAGE Is English your preferred Language? es o, What is your preferred language? MAIN PROVIDER Primary Care Physician: Referring Physician: Phone Number: Phone Number: Current problem or reason for consultation: VACCINATIONS Vaccination Last Administration Date (MM/YYYY) Vaccination Last Administration Date (MM/YYYY) Pneumonia Hepatitis B Flu DT Shingles DPT Pneumococcal Tetanus Tuberculosis (TB) Other PAST MEDICAL HISTORY: PLEASE CHECK ALL THE BOXES THAT APPLY Anemia/Blood disorders Emphysema Pancreatitis Arthritis GERD Sickle Cell disease Asthma Glaucoma Sinusitis Autoimmune disease Heart Disease Stroke Blood Clots Hepatitis/Liver disease Thyroid Cancer Hypercholesterolemia Tuberculosis Cataracts Hypertension Ulcers Colitis Irregular heartbeat Other: Diabetes Kidney disease Any unusual childhood infections or illnesses? FRM-005 Version 1.0 Effective Date: 01 JAN 2018 Page 1 of 8
2 MEDICAL SURGICAL HISTORY Operation Date (MM/YYYY) Reason Surgeon/Facility HOSPITALIZATION Have you been hospitalized with in the last year? es o If yes, please describe reason, facility and dates: SCREENING TESTS Have you had any screening tests? Screening Test Completed Date Results Mammogram Breast Exam Pap Smear/Pelvic Exam Stool for Occult Blood Colonoscopy/Sigmoidoscopy Prostate Exam PSA Chest X-Ray/CT (Smokers) Bone Density Dermatology Skin Screening Eye Exam Other: FRM-005 Version 1.0 Effective Date: 01 JAN 2018 Page 2 of 8
3 SOCIAL HISTORY Number of Children: Age/Sex of Children: Spouse/Partner s Name: ALCOHOL USE Do you drink beer, wine, or liquor? es o If yes, How many drinks per: Day: Week: Month: Year: Did you quit? es o When did you quit? Have you ever sought help for drinking? es o SMOKING USE Do you currently smoke? es o If yes, what do you smoke? Cigarettes Cigars Pipe Electronic Cigarettes Smokeless/Chewing Tobacco Did you ever smoke? es o If yes, how long did you smoke for? When did you quit? Do you wear a nicotine patch? DRUG USE (RECREATIONAL) Do you use recreational drugs, including marijuana? es o If yes, what do you use: How often: If marijuana, is it medical marijuana? es o Have you previously used recreational drugs? es o If yes, when did you quit: FRM-005 Version 1.0 Effective Date: 01 JAN 2018 Page 3 of 8
4 PREFERRED PHARMACY Please indicate the pharmacy you are currently using for your prescriptions. If you are using a mail order pharmacy, specialty pharmacy or another pharmacy out of state, please include that information as well. Pharmacy Name: Type (circle one): Retail Mail Order Specialty Address/Cross Roads: City: State: Zip Code: Phone number: Fax number: Pharmacy Name: Type (circle one): Retail Mail Order Specialty Address/Cross Roads: City: State: Zip Code: Phone number: Fax number: MEDICATION LIST Please list all the medications you are currently taking. Be sure to include the dosage, how often and the doctor that has prescribed this medication for you. If you are taking any vitamins, over the counter medications or herbal supplements please also include these medications in the list below (you do not need to include the prescribing physician if not applicable). Drug Name PRESCRIPTION / OVER-THE-COUNTER Dose/Strength of Medication How often you take Medication Prescribing Physician Please list any herbal supplements you are currently taking (probiotics, vitamins, etc.). Herbal Supplements Dose/Strength How often you take Supplement FRM-005 Version 1.0 Effective Date: 01 JAN 2018 Page 4 of 8
5 ALLERGIES Do you have any allergies? es o If yes, please list any medications, food or substances that you are allergic to. If applicable, please list the reaction (i.e. swelling, itching, shortness of breath, etc.) Name of medication, food or substance: Type of Reaction: FRM-005 Version 1.0 Effective Date: 01 JAN 2018 Page 5 of 8
6 FAMILY MEDICAL HISTORY Please mark (Y) for all those that apply to YOUR FAMILY. Please mention relationship(s) to you and the age of diagnosis for each cancer in your family. The following close blood relatives should be considered: You, parents, brothers, sisters, sons, daughters, grandparents, grandchildren, aunts, uncles, nephews, nieces, half-siblings, first cousins, great grandparents & great grandchildren. YOUR FAMILY s Cancer History (Please be as thorough and accurate as possible) Y CANCER EXAMPLE: BREAST CANCER BREAST CANCER (Female or Male) OVARIAN CANCER (Peritoneal/Fallopian Tube) UTERINE (ENDOMETRIAL) CANCER COLON/RECTAL CANCER 10 or more LIFETIME COLORECTAL POLYPS (Specify #) OTHER CANCER(S) (Specify cancer type) YOU AGE OF DIAGNO SIS PARENTS / SIBLINGS / CHILDREN Are you of Ashkenazi Jewish descent? AGE of Diagnosis RELATIVES on your MOTHER S SIDE Aunt Cousin Are you concerned about your personal and/or family history of cancer? AGE of Diagnosis Have you or anyone in your family had genetic testing for a hereditary cancer syndrome? (Please explain/include a copy of result if possible) RELATIVES on your FATHER S SIDE Grandmother 53 AGE of Diagnosis For other close blood relatives such as grandparents, aunts and uncles: Please check all boxes that apply Anemia/Blood Disorders Diabetes Hypertension Blood Clots Heart Disease Stroke Blood Disorders FRM-005 Version 1.0 Effective Date: 01 JAN 2018 Page 6 of 8
7 REVIEW OF SYSTEMS General Fever Weight Loss Fatigue Chills Weight Gain ight Sweats Headaches Ringing in ears Toothache Blackouts Sinusitis Double Vision Seizures Post Nasal Drip Blurred Vision Head Dizziness Sore Throat Cataracts Hearing Loss Hoarseness Glaucoma Earache Sore Tongue Bleeding Gums osebleeds Neck Lumps Goiter Pain or Stiffness Pain when swallowing Difficulty swallowing Cough Shortness of Breath Heart Murmur Sputum Chest Pain Rheumatic Fever Chest Coughing Up Blood Palpitations High Blood Pressure Wheezing Swelling of feet Bronchitis Asthma Breast Lumps Pain ipple Discharge Abdomen Urinary Gynecology ausea Ulcer Hemorrhoids Vomiting Gas Blood in stools Indigestion Bloating Black stools Abdominal pain Constipation Hiatal Hernia Diarrhea Blood in urine Difficulty starting to Getting up at night to urinate urinate Burning with urination Bladder/Kidney Sense of full bladder Infections Frequent urination Spotting Cramping Discharge Vaginal infections Last Menstrual Period: Duration: Interval: Number of pregnancies: Number of live births: Skin Rash Itching Change in hair or nails Neuromuscular Joint Stiffness Swelling ight Cramps Joint Pain Back Pain Varicose veins Hematological Easy bruising or bleeding Anemia Past Infusion Transfusion Reactions Endocrine Thyroid Problems Hot or cold intolerance Excessive thirst or hunger Psychiatric Anxiety Depression Memory Loss ervousness FRM-005 Version 1.0 Effective Date: 01 JAN 2018 Page 7 of 8
8 OTHER PROVIDERS Please list all providers involved in you care within the last 3 years: Provider Type Physician (first and last name) Phone Number Primary Care Physician Surgeon Cardiologist Endocrinologist Neurologist Urologist Pulmonologist Dentist Oral surgeon Optometrist Orthopedic Gynecologist Podiatrist Dermatologist Rheumatologist Other: Patient Signature: Date: FRM-005 Version 1.0 Effective Date: 01 JAN 2018 Page 8 of 8
PATIENT HEALTH HISTORY
DEMOGRAPHICS Name: Date of Birth: Sex: Male Female Ethnicity (optional): Hispanic or Latino Not Hispanic or Latino Race (optional): White Black or African American Other: PREFERRED LANGUAGE Is English
Patient Health History
Patient Health Histry Name: Date f Birth: Age: SS #: Tday's Date: Sex: Male Height: Female Primary Care Physician: Phne Number: Referring MD: Phne Number: Other MD's: Name/Specialty Pharmacy Name: Pharmacy
Patient Health History
Patient Health Histry Name: Date f Birth: Age: SS #: Tday's Date: Sex: Male Height: Primary Care Physician: Phne Number: Referring MD: Phne Number: Other MD's: Name/Specialty Pharmacy Name: Pharmacy Number:
Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, www.coainc.cc Ph: 614.442.3130, Fax: 614.442.3145 Name (Last, First, Middle) Birth Date Age Social Security # Appointment
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Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Patient History Form
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Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
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Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
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