J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health
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1 J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health Patient Clinical Information Questionnaire 1.0 Date of Questionnaire Completion; / / 2.0 Patient Data 2.1 Name: 2.2 Address: 2.3 Phone #: (H) ( ) - (W) ( ) - (C) ( ) - Fax#: ( ) Date of Birth: / / 2.5 Age: 2.6 Sex: 2.7 Height: 2.8 Weight: 3.0 Who referred you to Dr. Van Lier Ribbink?
2 4.0 Who are your doctors? Name (last/first initial) Specialty City Social History Yes No 5.1 Single 5.2 Married 5.3 Widowed 5.4 Separated 5.5 Divorced 5.6 Children 5.7 Ages of Children 5.8 Occupation 6.0 Why are you seeing Dr. Van Lier Ribbink?
3 7.0 What allergies do you have to medications? Medication Reaction What prior surgeries have you had? Do you presently or have you had in the past any of the following problems or conditions? 9.0 BREAST Yes No 9.1 Breast cancer 9.2 Breast lumpectomy 9.3 History of breast cancer in relatives 9.4 Mastectomy 9.5 Radiation therapy to breast 10.0 CARDIOVASCULAR 10.1 Angina 10.2 Chest Pain 10.3 Congestive heart failure 10.4 Deep venous thrombosis 10.5 Defibrillator placement
4 Do you presently or have you had in the past any of the following problems or conditions? 10.0 CARDIOVASCULAR Yes No 10.6 Heart artery angioplasty 10.7 Heart artery stent placement 10.8 Heart attack 10.9 Heart rhythm problem Heart valve problem High blood pressure Pacemaker placement Pain in calves when walking 11.0 CEREBROVASCULAR 11.1 Seizures 11.2 Stroke 11.3 Temporary arm or leg weakness 11.4 Temporary blindness 11.5 Temporary difficulty speaking 11.6 Temporary paralysis 11.7 Temporary ischemic attack 12.0 DERMATOLOGY 12.1 Basal cell skin cancer 12.2 Itching 12.3 Melanoma 12.4 Skin cancer 12.5 Squamous cell cancer 12.6 Ulcerated skin lesions 13.0 ENDOCRINE 13.1 Adrenal tumors 13.2 Diabetes 13.3 Drinking excessive water 13.4 Excessive sweating 13.5 Excessive thirst 13.6 Fatigue 13.7 Flushing 13.8 Frequent bone fractures 13.9 Hair loss Hashimoto s Thyroiditis Headaches
5 13.0 ENDOCRINE cont d Yes No Heat intolerance High blood calcium levels History of adrenal tumors in relatives History of hyperparathyroidism in relatives History of Multiple Endocrine Neoplasia Syndromes (men syndrome) in relatives History of pancreas tumors in relatives History of parathyroid tumors in relatives History of pituitary tumors in relatives History of thyroid tumors in relatives Hoarseness Hyperparathyroidism Hyperthyroidism Hypothyroidism Increased appetite Joint aches Low potassium levels Memory problems Multiple Endocrine Neoplasia Syndrome (men syndrome) Muscle aches Muscle cramps Neck pain Numbness Pancreas tumors Parathyroid tumors Pituitary tumors Radiation therapy to head, neck and chest Seizures Thinking slowly Thyroid goiter Thyroid nodules Thyroid tumors Tingling Treatment with radioactive iodine 131 for goiter, Grave s disease, or thyroid cancer Tremor Weight gain Weight loss
6 Do you presently or have you had in the past any of the following problems or conditions? 14.0 GASTROINTESTINAL Yes No 14.1 Abdominal pain 14.2 Abdominal wall hernia 14.3 Black coffee ground material in vomit 14.4 Black stool 14.5 Chronic ulcerative colitis 14.6 Clay colored stool 14.7 Colon cancer 14.8 Colon cancer in relatives 14.9 Colon polyps Constipation Crohn s disease Decreased stool diameter Diarrhea Difficulty swallowing Fever Gallbladder problems in relatives Gallbladder stones Gastroesophogeal reflux disease (GERD) Groin hernia Heartburn Hemorrhoids Hepatitis Irritable bowel syndrome Jaundice Loose stool Nausea Pancreas cancer in relatives Pancreatitis Poor appetite Red blood in stool Red blood in vomit Trauma to abdomen Ulcer disease Vomiting Weight loss
7 Do you presently or have you had in the past any of the following problems or conditions? 15.0 GYNECOLOGY Yes No 15.1 Cancer of the ovaries 15.2 Cancer of the uterus 15.3 History of cancer of the ovaries in relatives 15.4 History of cancer of the uterus in relatives 15.5 Ovarian cancer 15.6 Pregnant currently 15.7 Vaginal discharge 16.0 HEMATOLOGY 16.1 Anemia 16.2 Blood transfusion 16.3 Excessive bleeding with surgery 16.4 Leukemia 16.5 Low platelet count 16.6 Lymphoma 16.7 Night sweats 16.8 Sickle cell anemia 17.0 NEUROLOGY 17.1 Alzheimer s disease 17.2 Coma 17.3 Confusion 17.4 Difficulty concentrating 17.5 Double vision 17.6 Headaches 17.7 Head injury 17.8 Impaired hearing 17.9 Multiple sclerosis Ringing in ears Seizures 18.0 OPTHALMOLOGY 18.1 Blindness 18.2 Blurred vision 18.3 Cataracts 18.4 Double vision 18.5 Glaucoma 18.6 Macular degeneration
8 19.0 PULMONARY Yes No 19.1 Asthma 19.2 Cough 19.3 Coughing up blood 19.4 Chronic Obstructive Pulmonary Disease 19.5 Cigar use 19.6 Cigarette use 19.7 Difficulty breathing 19.8 Emphysema 19.9 Home oxygen therapy Lung nodules Pulmonary embolus Tuberculosis Valley fever 20.0 PSYCHIATRIC 20.1 Agitation 20.2 Anxiety 20.3 Bipolar mood disorder 20.4 Depression 20.5 Mood swings 20.6 Nervous breakdown 20.7 Nervousness 20.8 Poor motivation 20.9 Schizophrenia 21.0 UROLOGY 21.1 Air bubbles in urinary stream 21.2 Dark cola colored urine 21.3 Difficulty initiating urinary stream 21.4 Flank pain 21.5 Frequent urination 21.6 Kidney stones 21.7 Pain with urination 21.8 Red blood in urine 21.9 Urinary incontinence Urinating large amounts Waking up to urinate frequently
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