2. About your most recent breast imaging: None( ) Date Facility Mammogram Breast MRI Ultrasound
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1 Today s Date: / / MM DD YYYY Date of Birth: Best Phone Number / / Last Name First Name MM DD YYYY address Names and addresses of health care providers we should send reports to: 1. Check as many boxes as you need to tell us the reason(s) for your visit Right Left I have recently been diagnosed with a new breast cancer I have a breast cancer recurrence I am experiencing nipple discharge About the discharge (circle): clear bloody spontaneous I have a lump in my breast About the lump (circle): 1st felt by doctor 1st felt by you My breast imaging (mammogram, sonogram, MRI) is abnormal I have a rash on my breast or nipple I have lumps in my arm pit I am having breast pain About the pain (circle): one spot all over I am here for breast cancer risk assessment I am here for breast imaging (mammogram, sonogram Other (specify) Provider Notes 2. About your most recent breast imaging: None( ) Date Facility Mammogram Breast MRI Ultrasound 3. Are you currently pregnant or breast feeding? No Yes 4. How old were you when you had your first menstrual period? 5. Have you had a baby? No Yes; Your age when your first was born: 6. Respond to the statement that best describes your menstrual cycles: I have had a menstrual period in the last year (date the last period started) I stopped having menstrual periods naturally (enter age this happened) I stopped having periods when my ovaries were removed (enter age) I stopped having menstrual periods because of chemotherapy (enter age) I m not sure about my periods because I had my uterus removed (but not my ovaries) or had an ablation while I was still having periods ( the box) 1
2 7. List the medications you are taking now. Include prescription medications, over-the-counter medications, herbal supplements, and Check any of the following diet pills. No Medications you are CURRENTLY using Name of Medication Dose How Often Reason Blood thinners Tamoxifen Depo-provera IUD Check any of the following you have EVER used Tamoxifen or Raloxifene Aromatase inhibitor (arimidex, femara ) Estrogen blocker (faslodex) 8. Allergic Reactions (medications, foods, latex ) No Allergies Check if you have ever Allergy Reaction had an allergic reaction to CT or MRI dyes 9. About hormone replacement therapy: Never used (skip to #10) Age you first started taking hormones Age you last took hormones (write now if still using them) Check all of the boxes that describe the types of hormones you took Estrogen only Estrogen plus progesterone (e.g. Prempro) Compounded bio-identical hormones Over-the-counter herbal or plant hormones 10. How many breast biopsies have you had that were negative for cancer? (This includes open surgery biopsies or needle biopsies, but not drainage of a cyst.) Did any show atypical hyperplasia or lobular carcinoma in situ? Yes No Don t Know 11. Breast Surgeries and Treatments You Have Had (check all that apply) None: Right Left Age(s) Breast Biopsy Breast implant placement Breast implant removal Breast reduction Breast lift Mastectomy with removal of the nipple Mastectomy without removal of the nipple Lumpectomy Axillary sentinel lymph node biopsy Axillary dissection (removal of all of the arm pit lymph nodes) Autologous tissue flap reconstruction (e.g. TRAM, DIEP) A breast reconstruction that failed Fat grafting as part of breast reconstruction Breast radiation treatments 2
3 12. Cancer Family History. I don t know anything about my family history (skip this section) Do you have any Ashkenazi Jewish ancestry in your family? Yes No Don t know Are there any men in your family who have had breast cancer? Yes No Don t know If Yes, relationship: Have you ever had genetic testing? No Yes Don t know If Yes, Result: positive, gene negative don t know Have any of your relatives had genetic testing? No Yes Don t know If Yes: Relative Result: positive ; gene negative How many sisters does your mother have? How many sisters does your father have? Please fill in the number of breast and ovarian cancers in your family below: No breast or ovarian cancer Side of the Family Relative Number of relatives with breast cancer Number of relatives with breast cancer age Number of relatives with ovarian cancer before age or older Mother, sisters, and daugters Nieces Mother s Side Aunts or grandmother Cousins, Great Aunts Father s Side Aunts or grandmother Cousins, Greast Aunts Please tell us about any other cancers either you or a family member have had: Relative Type of Cancer Age at Diagnosis 3
4 13. Race (check one) Ethnicity (check all that apply) African-American Hispanic or Latino American Indian/Alaskan Native Ashkenazi Jewish Asian Not Hispanic, Latino or Ashkenazi Jewish Caucasian Native Hawaiian/Pacific Islander Other: 14. Check the box the best describes your current health I m fully active and able to take care of myself I can do light house or office work, but I am a bit limited on strenuous physical activity I m up and about more than half the day. I can walk and take care of myself but cannot work I m in the bed or a chair more than half the day and need help taking care of myself I m completely disabled. I spend nearly all my time in the bed or a chair and need a lot of help 15. If you have ever been pregnant: Never been pregnant How many times have you been pregnant? How many babies were delivered alive? How many abortions or miscarriages have you had? How old were you when the last living baby was born? About Breast Feeding: Never breast fed Age you first breast fed? Total number of months you breast fed? 16. If you ever used birth control pills. Never used Age you first took birth control pills Age you last took birth control pills Check the box that best describes your use of birth control pills I used birth control pills pretty much every month I used birth control pills on and off 17. If you have ever used fertility medications. Never used Age when you used fertility medications Approximate number of months 18. Family Medical History None Illness Relatives (e.g. brother, mother ) Heart attack or heart failure Stroke or TIA Blood clots in the legs or elsewhere High blood pressure Bleeding tendency Problems with anesthesia Osteoporosis Other (specify) 4
5 19. Your Medical Conditions (check all that apply) None: High blood pressure Arthritis Hepatitis Diabetes Anemia (low red cell count) Cirrhosis of the liver High cholesterol or lipids Epilepsy (seizures) Kidney infections Heart attack Low thyroid Kidney stones Heart failure Overactive thyroid Kidney failure Stroke or TIA Blood clots Cataracts Irregular heart rhythm Bleeding tendency Glaucoma Asthma Colon polyps Tuberculosis Emphysema or COPD Stomach or duodenal ulcers HIV/AIDS Osteopenia/osteoporosis Numbness or nerve pain MRSA or VRE Lupus or Scleroderma Gastroesophageal Reflux Other: 20. List any surgeries or procedures you have had other than the breast surgeries already listed under item #11 (be sure to include things like coronary stents, balloon dilations, ablations ) None Surgery/Procedure Year Problems or Complications 21. Radiation Exposure Radioactive iodine treatments: No Yes -> Year Radiation treatments (other than breast): No Yes-> Year Reason: Other radiation (describe): 22. Social History Marital Status (circle): Married or Partnered Separated Divorced Widowed Never Married Highest Education Level: Elementary Middle School High School College Graduate School Tobacco: Never Age first used Age last used usual packs/day Alcohol (last 3 mo): None less than 1/week 1/week or more: drinks per week Illicit Drug Use: Never Past Current Drugs (past or current): Employment: Retired Unemployed Disabled or Current position: Physical Activity Hours per week walking, running, lap swimming, bicycling or other sport activities: hrs Hours per week sitting at work or at home using a computer, watching TV, or reading: hrs 5
6 Are you Jehovah s Witness? No Yes 23. What is your bra size (chest and cup)? How do you feel about your bra cup size? I am happy with my current size I want to be larger I want to be smaller 24. Check all that apply to you Anesthesia and Airway I have never had general anesthesia Sleep apnea (e.g. use a CPAP machine) I have been told I have a difficult airway Snoring loud enough to hear in another room I have had an unusual reaction to anesthesia Frequently tired during the day Describe: Someone has observed your breathing stop Check any symptoms you have had in the last 6 months General Gynecologic Gastrointestinal Fever Abnormal vaginal bleeding Heartburn Fatigue Vaginal dryness Stomach pain Unexplained weight loss Vaginal discharge No appetite Weight gain Painful intercourse Nausea/vomiting Night sweats Diarrhea Rashes Urinary Constipation Difficulty urinating Blood in stools Musculoskeletal Painful urination Back pain Frequent urination Cardiac Bone pain Blood in urine Chest pain Joint pain Dribbling or incontinence Palpitations Arm swelling Ankle swelling Muscle pain Neurological Shortness of breath Frequent headache Can t lay flat Psychiatric Vision change Anxiety/panic Dizziness Respiratory Depression Numbness/tingling Cough Suicidal thoughts Frequent falls Easily winded Bipolar/Schizophrenic Tremors Sinus problems Incoordination Wheezing Any other symptoms: 25. Is there anything else we should know about you? 6
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Ginger N. Cathey, MD Urogynecology 7900 Fannin, Suite 4000 Houston, TX 77054
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Patient Interview Form
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Appointment Page 1 Chief Complaint: (reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History EYES Yes No Yes Details Glaucoma EAR, NOSE AND THROAT Hearing difficulty
Name Appointment Date. Age Date of Birth Date Completed
Urogynecology Center Name Appointment Date Age Date of Birth Date Completed Reason for Visit Please provide Name, Address, Phone Number, and Fax Number for the following Physicians or Healthcare Providers
UnityPoint Clinic - Cardiology
UnityPoint Clinic - Cardiology Date Completed: Appointment Date: Name: Age: Birthdate: / / FIRST MIDDLE INITIAL LAST Referred by: Family Dr.: Reason for visit: Describe briefly, include date of onset:
*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Last Name: First Name: Date Form Completed: Referring Physician: Address: City: Sex: Marital Status: Race: Age: Married Caucasian Single Male Divorced African American Hispanic
Patient Information First Name: Last Name: Middle Initial: Date of Birth: Sex: Male Female
Place Patient Sticker Here Patient Information First Name: Last Name: Middle Initial: Date of Birth: Sex: Male Female Social Security # Marital Status: Single Married Divorced Widowed Ethnicity: Non Hispanic
REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL
REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL NAME: BIRTH DATE: AGE: SEX: M F OCCUPATION: RACE: WHO REFERRED YOU TO OUR OFFICE? _ WHAT IS YOUR MAIN COMPLAINT? HOW LONG HAS THIS BEEN A PROBLEM? IS
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
GIDEON G. LEWIS, M.D.
GIDEON G. LEWIS, M.D. Date: LAST Name: FIRST Name: MIDDLE Initial: Address: City: State: Zip Code: Date of birth: / / Social Security #: - - Sex: M F Marital Status (Circle): Single Married Divorced Widowed
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
THE OB/GYN CENTRE NEW PATIENT HISTORY
PERSONAL PROFILE NAME: AGE: NAME YOU WOULD LIKE US TO USE: OCCUPATION: MARITAL STATUS: GYNECOLOGICAL HISTORY LAST MENSTRUAL PERIOD (FIRST DAY): AGE PERIOD BEGAN: PRESENT BIRTH CONTROL PAST METHODS OF BIRTH
New Patient Health Information
MEDICAL FACULTY ASSOCIATES DEPARTMENT OF GENERAL SURGERY DIVISION OF BARIATRIC SURGERY 1011 NEW HAMPSHIRE AVE, NW WASHINGTON, DC 20037 New Patient Health Information The information obtained from this
Urogynecology New Patient Form
Urogynecology New Patient Form Today s Date: Appointment Date: PATIENT INFORMATION Patient Name: Marital status: Is this your legal name? If not, what is your legal name? Birth date: Age: Reason for Visit:
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)