Patient: Age: Date: Height Weight Alternative Telephone number: Occupation: Do you have a living will or advance directive? YES NO
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1 , M.D., Jennifer Halpern, M.D. Orthopaedic Oncology Patient Questionnaire Initial Evaluation Patient: Age: Date: Height Weight Alternative Telephone number: Occupation: Do you have a living will or advance directive? YES NO 1. Please describe your problem. 2. How does the problem affect work and social activities? 3. Please list the physicians who have cared for you. 1
2 Medications List all drugs you are currently taking Strength Times per day Allergies Are you allergic or intolerant of (check all that apply) No Known Allergies Penicillin Sulfa Erythromycin Codeine Demerol X-ray dye Iodine Keflex Other Rash Nausea or Vomiting Shock Other (describe) Health Maintenance When was your last.. Month/yr Never Not Sure Explain any abnormal results Cholesterol test Stool test for blood Sigmoidoscopy/Colonoscopy Tetanus booster Flu shot Pneumonia vaccine Mammogram Breast exam by physician Pap smear Self-breast exam PSA 2
3 Family History Please indicate any family member who has had the following: Heart disease Father Mother Brother Sister Aunt or Uncle Grandparent Child Com ment s High blood pressure Stroke Lung Cancer Kidney disease or cancer Breast cancer Cancer of the ovary Prostate cancer Colon cancer Tuberculosis Psychiatric illness Sickle cell disease Unexplained sudden death Bone cancer Skin cancer Soft tissue/muscle cancer Neurofibromatosis Lipoma Diabetes Melanoma Bleeding tendencies Osteochondromatosis Others 3
4 Have you recently had: Frequent or severe headaches Dizziness Falling out spells Seizures or convulsions Problems with ears/vision Times when you become numb, paralized, unable to speak clearly, or blind in one eye that comes and goes for no apparent reason Ringing in your ears Earaches Trouble Hearing Problems with your eyes or vision Wear contact Lenses Approx date of last eye exam: _ Sinus problems Allergies Nosebleeds Mouth or teeth Trouble swallowing Frequent sore throats Hoarseness Change in your voice Wear dentures Lumps or bumps, swollen glands, knots Problems or changes in your skin Rash Itching Spots or moles that have changed Frequent or non-healing sores Fevers, chills, or sweats for no apparent cause Feeling tired or having low energy Trouble sleeping Change in mood Little interest or pleasure in doing things Feeling down, depressed or hopeless Problems with nerves or feeling anxious or "on edge" Do you find yourself worrying about a lot of different things Have you experienced any new major stresses or changes Have you ever had an anxiety attack (sudden unexplained fear or panic) Has anyone complained about your alcohol consumption? Have you ever felt guilty or upset about your alcohol consumption? Consumed more than 4 drinks of beer, wine, orliquor in a single day? Any change in your breasts Problems with your lungs or your breathing Coughing Awaken at night smothering Wheezing Created by Ginger E. Holt, M.D. 4
5 Had a heart murmur Other change in bowel habits Constipation Diarrhea Change in appearance of stools Black, tarry stools or blood Hemorrhoids Trouble with bladder or kidneys Diffculty voiding Urinating too often Getting up at night often to void Frequent bladder infections Blood in your urine Pain or problems during sexual intercourse Problems getting started in the mornings Coughing up blood Have to prop yourself up to breath at night Chest Pain Arm, neck or jaw pain with exertion Feeling your heart pound, skip or race Ankle Swelling Change in weight or appearance Indigestion or heartburn Nausea Vomiting Abdominal Pain Straining to void Dribbling at end of stream Do you experience any of the following with your muscles or joints? Joint Pain Stiffness Joint Swelling Back Pain Calf or leg cramps while walking FEMALE ONLY Date of last menstral period: How many times have you been pregnant? _ Do you suffer from: Irregular Periods Heavy Periods Vaginal Discharge Vaginal bleeding after menopause What is your current contraception, if applicable: None Foam Pill Tubal Ligation Diaphragm Condom IUD N/A 5
6 Fractures: Please list all fractures you have had in the past Bone Brace/Cast/Surgery Date Have you ever been diagnosed with Osteoporosis? yes no If so, have you had either of the following tests performed? Dexascan DATE Biopsy Have you ever been on any of the following therapies? Calcium Vitamin D Estrogen Bisphosphonate (Fosamax) Calcitonin Pyrolinks Operations Operations Date Surgeon Appendectomy Tonsillectomy/ Adenoids Gallbladder Operation Coronary bypass Hernia repair Hemorrhoid operation Hysterectomy and ovaries Tubal ligation Breast biopsy Mastectomy Prostate (TURP) Vasectomy Cataract operation Joint Bone Other Operations: 6
7 Have you ever been diagnosed with: Rheumatic fever Tuberculosis or (+) TB skin test Hepatitis Gonorrhea or syphilis HIV infection Genital herpes Other: Comments Other illnesses and hospitalizations High blood pressure Heart attack Diabetes Depression Asthma or chronic lung disease Cancer Blood clots Kidney stones Heart failure Blood transfusions Stomach ulcers Kidney disease Dialysis Other: Comments 7
8 Personal Habits Use any form of tobacco Type Approximate Quit Date, if applicable Now In the past Drink alcohol? Average amount per week: Drink coffee? Average # of cups per week: Wear seat belts regularly? Exercise at least 3x/ week Crutches/ cane Wheelchair Issues regarding sexual history, recreational drug use, domestic violence, or other concerns of a personal nature should be discussed with the physician. I have reviewed this information and confirmed with the patient. MD Date 8
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Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).
Name: Date: Referring Provider: Age: D.O.B. Race/ ethnicity: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). We are interested in learning
Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which: