New Endocrinology Patient Medical History
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- Doris Fitzgerald
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2 New Endocrinology Patient Medical History Personal information Date of first appointment Last name Middle name or initial Time of appointment First name Maiden name Street (mailing) address City State Zip Birthplace Birthdate Sex n female n male Marital status n never married n married n divorced n separated n widowed Spouse/significant other n alive age n deceased at age Spouse s or significant other s major illnesses Education Grade school n 7 n 8 n 9 n 10 n 11 n 12 College n 1 n 2 n 3 n 4 Graduate school? n yes n no If yes, school name Referral Referred by n self n family n friend n doctor n other health professional If other than self, name of person who referred you Purpose of visit Describe your present symptoms Surgeries and hospitalizations Type Year Reason NEPH Page 3 of 14 Page 1 of 4
3 Page 2 of 4 Medicines, vitamins, supplements, herbs Name (example: Lipitor) Dose (example: 10 mg) Frequency (example: once a day) I am allergic to these medications/foods/dyes Diabetes/elevated glucose patients only Date of last diabetic eye exam month year Date of last podiatry/foot exam month year Date of last dental exam month year Date of last nutritionist/diabetes educator visit month year Do your parents/siblings/children have (or had) Heart attack/heart bypass surgery/stent n don t know n yes n no Age? Stroke n don t know n yes n no High cholesterol n don t know n yes n no Obesity n don t know n yes n no Adult diabetes n don t know n yes n no Juvenile, Type 1 diabetes n don t know n yes n no Thyroid disease n don t know n yes n no What kind? Cancer n don t know n yes n no Where did it start? Osteoporosis, hip fracture n don t know n yes n no Age? Rheumatoid arthritis, lupus, multiple sclerosis? n don t know n yes n no Page 4 of 14
4 Page 3 of 4 Please mark any of the following symptoms that you are experiencing. General n unexplained rapid weight gain n fever n unexplained rapid weight loss n extreme tiredness Endocrine n excessive sweating/night sweats n low blood sugar n calcium problems n potassium problems n heat/cold intolerance n adrenal problems n thyroid problems n pituitary problems Eyes n eye laser treatments n glaucoma n poor vision/blindness n macular degeneration n color blindness n tunnel vision (poor peripheral vision) n double vision n retinal detachment ENT n loss of hearing/deafness n dentures/bridges n mouth dryness n difficulty swallowing n changes in voice, hoarseness n pain in front of the neck n enlarged thyroid or neck lumps n impaired smell or taste Heart/lungs n use oxygen n sleep apnea, use CPCP/BiPAP n shortness of breath on exertion n pacemaker or internal defibrillator n blood in sputum n short of breath at night/rest n chest/arm/jaw discomfort on exertion n asthma or COPD n slow, fast or irregular heart beat n long term cough n ankle/leg swelling with water n calf pain while walking Breast n nipple discharge n breast lump/mass n breast pain/tenderness or swelling Gastrointestinal n nausea n vomiting n early satiety n eating disorder n diarrhea n constipation n irritable bowel n crohn s disease or colitis n frequent heartburn, indigestion n abdominal pain n bloody or black, tarry stools n food intolerances Blood n history of blood clots n bleeding problems n easy bruising n anemia n radiation treatments to head, neck or whole body Urological n frequent bladder or vaginal infections n kidney problems n kidney stones n frequent urination Men only n pain or lump in testicles n STD/discharge n difficulty achieving/maintaining erections n change in desire to have sexual intimacy (libido) Page 5 of 14
5 Page 4 of 4 Women only n date of last period n irregular periods n spotting between periods n pregnant now Number of pregnancies Number of live births n contraception use (birth pill, iuds, condoms, vasectomy) Muscle/bones n muscle aches n muscle weakness n gout n arthritis n fractures n amputations Skin n foot/leg ulcers n skin rash n darkening or lightening of the skin n dry skin n hair loss n brittle nails Neuro/psych n frequent severe headaches n dizziness n previous head injury n unsteady gait n seizures n loss of consciousness n paralysis n tremor n burning, shooting pain in hands/feet n decreased sensation/feet n memory loss n depression/anxiety/fears Anything else you would like us to know about you? Page 6 of 14
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
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John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter
John Wayne Cancer Institute Dr. Foshag Essner Dr. Fischer Dr. Faries Dr. Foshag Dr. Bilchik Dr. O'Day Dr. Leuchter Medical Questionnaire Reset Form Date: Name: Gender: Male Female Age: Last First Middle