SELF-REPORTING HEALTH HISTORY

Transcription

1 SELF-REPORTING HEALTH HISTORY DATE: DEMOGRAPHIC INFORMATION : Age: Address: City: State: Zip Code: Work Phone: Home Phone: Fax Number: Significant Other : Phone: CHIEF COMPLAINT - HISTORY OF PRESENT ILLNESS Reason for visit today? Consultation alone Consultation plus ongoing care Consultation and uncertain regarding ongoing care Were you referred to the physician you are seeing: Yes No By whom? Were you referred to the SCCA Yes No By whom? Onset of illness: Date Symptoms: PAST RADIATION THERAPY STARTED STOPPED AREA OF BODY TREATED PAST DRUG TREATMENT FOR CANCER STARTED STOPPED AREA OF BODY TREATED PAST HOSPITALIZATIONS AND/OR SURGERY (Operations) - Please list chronologically YEAR PROBLEM HOSPITAL DOCTOR PAST SERIOUS ACCIDENTS TYPE YEAR PAST TRANSFUSION HISTORY WHEN WHERE COMPLICATIONS CHILDHOOD ILLNESS YOU HAVE HAD (Please check those that apply) Whooping Cough Rheumatic Fever Scarlet Fever Mumps Measles Rubella Chicken Pox Other (please list): SELF-REPORTING HEALTH HISTORY PAGE 1 OF 7

2 OTHER ILLNESS WHICH YOU HAVE HAD TB Year of onset: High Blood Pressure Onset: Hepatitis Year of onset: High Cholesterol Year of onset: Lung Disease Year of onset: Heart Disease Year of onset: Depression Year of onset: Gall Bladder Disease Year of onset: FAMILY HEALTH STATUS: Relation Age State of Health If Deceased, Cause of Death Father Mother Siblings: Diabetes Year of onset: Liver Disease Year of onset: TB Year of onset: Kidney Disease Year of onset: Arthritis Year of onset: Nervous Breakdown Onset: Age at Death Your Spouse Children: Have any of your relatives had a cancer diagnosis? If yes, please list site of cancer Your Mother's parents Your Father's parents Your siblings Your aunts/uncles Cousins MALE MALE FEMALE FEMALE SKIN CHANGES Skin tumors/moles removed or burned Other Skin sensitivities/rashes Sweats NONE BREAST CHANGES Nipple discharge Other Lumps in breast Pain in breast NONE SELF-REPORTING HEALTH HISTORY PAGE 2 OF 7

3 HEAD AND NECK Do you currently wear any of the following: Glasses Contact Lenses Hearing Aid Dentures Blurring Vision Decrease/Loss of Hearing Bleeding gums Double Vision Ear Aches Trouble with Teeth Glaucoma Ringing/Buzzing in Ear Sore Mouth/Throat/Tongue Cataracts Hoarseness/Change in Voice Change in Taste or Smell Sinus Trouble Dry Mouth Frequent Laryngitis Nose Bleed Frequent Colds or Flu NONE OF THE ABOVE RESPIRATORY Do you have a history of: Pneumonia Bleeding Tuberculosis Emphysema Bronchitis Asthma Hay Fever Chronic Cough Chronic or frequent Infections/Colds Coughed-up Blood Fluid in Lung Shortness of Breath NONE OF THE ABOVE When was your last chest x-ray? Positive TB skin test Yes No CIRCULATORY High Blood Pressure Heart Attack Pain/Pressure in Chest/Angina Heart Failure Fast or Irregular Heart Beat Heart Murmurs Ankle Swelling Elevated Cholesterol Leg Pains NONE OF THE ABOVE GASTROINTESTINAL Do you have a history of: Cirrhosis Hepatitis Nausea or Vomiting Gall Bladder problems Abnormal Bowel movements Reflux or Heartburn Stomach/Liver or Intestinal trouble Recent changes in Bowel movements/habits Difficulty swallowing Gastritis or Stomach ulcers Abdominal pain/swelling Hemorrhoids Black stools or blood in stools Colostomy/Ileostomy Other: NONE OF THE ABOVE URINARY Do you have a history of: Kidney disease Frequent urination Difficulty with urination/slow Urostomy Painful urination start or weak stream Sugar/Albumin in urine Urgency Frequent urinary infection Kidney stones or blood in urine Frequent night time urination Incontinence of urine Urinary disease Kidney trouble Elevated PSA NONE OF THE ABOVE SELF-REPORTING HEALTH HISTORY PAGE 3 OF 7

4 NEUROLOGICAL Do you have a history of: Epilepsy/Seizure Mental Disorders Stroke Headaches - severe/frequent/ migraine Change in strength or sensation Change in thinking or memory Difficulty with coordination Numbness/tingling NONE OF THE ABOVE GYNECOLOGIC Age of onset of periods: Date of last period: Frequency and duration of period: Number of pregnancies: Number of live births: Have you ever used birth control (tubal ligation, pill, IUD, condoms, diaphragm)? Yes No If yes, type: For how long: When stopped: Present method of birth control: Date of last PAP smear: Menopause: Age of onset Currently taking estrogens Yes No Have you ever used estrogens Yes No Please indicate any Vaginal discharge/bleeding/cyst problems: Other: SEXUAL Are you sexually active? Yes No Do you experience sexual difficulties? Yes No Are you using any hormones (including birth control pills)? Yes No Do you have a history of sexually transmitted disease? Yes No ENDOCRINE/MUSCLE/SKELETAL Diabetes Arthritis Other Thyroid trouble/goiter Joint swelling or pain NONE OF THE ABOVE HEMATOLOGIC Bleeding disorders Swollen lymph nodes Previous transfusions Fatigue Anemia/clotting problems Other NONE OF THE ABOVE SOCIAL HISTORY Marital Status: Single Married ( years) Widowed Divorced Separated LANGUAGE SPOKEN ENGLISH NON-ENGLISH NEEDS TRANSLATOR Speaks: Family speaks: EDUCATION/VOCATION Highest grade completed: Current occupation is: Previous occupation: Have you had any exposure to: Asbestos Radiation Pesticides SELF-REPORTING HEALTH HISTORY PAGE 4 OF 7

5 RELIGION/CULTURE OPTIONAL: What is your religioius/spiritual affiliation? Are there religious beliefs/cultural traditions of which we should be aware during your treatment? Yes No If yes, please explain: LIFESTYLE Do you currently smoke? Yes No If yes, how many packs per day? How many years? Have you smoked in the past? Yes No If yes, how many years? Date you quit? Do you regularly drink beverages that contain caffeine? Yes No If yes, describe the type and how often: Do you regularly drink wine, beer, or other alcoholic beverages? Yes No If yes, describe the type and how often: Do you currently or have you used recreational drugs? Yes No If yes, describe the type and frequency in which you use(d) these drugs Have you served in the military? Yes No PSYCHOSOCIAL Do you live: Alone With family Other Do you have family or friends available to help you during your illness? Yes No Unsure Are you feeling any of the following: Sadness Yes No Depression Yes No Helplessness/Hopelessness Yes No Anxiety Yes No Fatigue Yes No NUTRITION Height: Weight: 1 year ago ; 6 months ago ; Current (actual) Have you had any changes recently in your eating habits? Yes No If yes, please check those that apply: Feeling full quickly Loss of desire to eat Soreness/dry mouth Change in taste/smell Difficulty swallowing Other: Do you have personal, cultural or religious dietary restrictions? Yes No If yes, please explain: ACTIVITY/REST Please rate your activity level: = in bed all of the time; 10 = normal activity Do you have difficulty sleeping? Yes No SELF-REPORTING HEALTH HISTORY PAGE 5 OF 7

6 PAIN: Please rate your pain over the last 24 hours: = no pain; 10 = severe pain On the drawings below, please shade the areas where you have pain FRONT BACK Check any words that describe your pain: Sharp Stinging Burning Constant Other: Shooting Dull Ache On/off Cramping Does your pain interfere with daily activities? Yes No Are you currently on medications for pain? Yes No If so, does it help? SELF-REPORTING HEALTH HISTORY PAGE 6 OF 7

7 : Address: PLEASE LIST ALL OF YOUR PRESENT PHYSICIANS Referring Physician Other Physician Other Physician Seen for current problem Seen for current problem Seen for current problem Telephone: Please send reports to this physician Please send reports to this physician Please send reports to this physician Do not send reports Do not send reports Do not send reports Patient's Signature: Date: If completed by someone other than patient: : Relationship: SELF-REPORTING HEALTH HISTORY PAGE 7 OF 7