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Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address: City: State: Zip: Home Phone: Mobile Phone: Email Address: Work Phone: Employer: Occupation: Emergency Contact: Relationship: Emergency Contact Phone (different than home phone): Status: Single Married Widowed Divorced Separated Sex: Male Female Race/ Ethnicity: Caucasian African-American Asian Native American Hispanic/Latino Other Primary Language: English Other Insurance Information Primary Insurance: Policy Number: Policy Holder s Name: Date of Birth: Relationship to Policy Holder: Group #: Secondary Insurance: Policy Number: Policy Holder s Name: Date of Birth: Relationship to Policy Holder: Group #: Tertiary Insurance: Policy Number: Policy Holder s Name: Date of Birth: Relationship to Policy Holder: Group #: Is this a: Workman s Compensation Claim? Yes No Auto Accident? Yes No If yes to above, please state the: Accident date: Claim #: Adjustor s Name: Phone: Rev1115

Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Current Medical Information Name: Age: Date: Main reason for today s visit: Please list all current medications: (please include non-prescription medication and supplements) Please list any allergies to medications or foods: known Latex allergy: yes no Reaction: Reaction: Reaction: Smoking History: Current Former Number of years: Packs per day: If quit, when? Would you like information on smoking cessation? Yes No Alcohol Consumption: Yes No If yes, how often? Rarely Socially Daily Environmental Exposure: Asbestos Radon Other Please list if you have any of the following specialists: Pulmonologist: Phone: Cardiologist: Phone: Internist/ primary care: Phone: Oncologist: Phone: Dermatologist: Phone: Other: Specialty: Phone: Rev11/15

Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Medical & Surgical History Name: Age: Date: Personal Medical History: Do you have (or have you had) any of the following conditions? Alcoholism Anemia Anxiety Arthritis- Rheumatoid Arthritis- Osteoarthritis Asthma Bipolar Disorder Blood clot- Leg Blood clot- Lung Blood transfusion Breast lump- Benign Cancer- Breast Cancer- Colon Cancer- Lung Cancer- Skin Cancer- Ovarian Cancer- Prostate Cancer- Uterine Cancer- other Cataracts Colon polyps Congestive Heart Failure Coronary artery disease Depression Diabetes- Insulin Dependent Diabetes- Non-Insulin Dependent Diverticulosis Drug use (recreational) Eczema Emphysema GERD/ Heartburn Glaucoma Gout Heart Attack Hepatitis A B C High blood pressure High cholesterol Hip fracture Hyperhidrosis (excessive sweating) Irritable Bowel Syndrome Kidney disease/failure Kidney Stones Liver disease Migraine headaches Osteoporosis Pneumonia Prostate Enlargement Psoriasis Seizure/ epilepsy Sleep apnea Stomach ulcer Stroke Thyroid nodule Thyroid, overactive Thyroid, underactive Other conditions/ Comments: Personal Surgical History: Please specify year of procedure on line provided. Appendectomy Back surgery Breast lumpectomy Brain surgery Coronary Bypass (CABG) Coronary stent EGD (upper endoscopy) Cataract procedure Gallbladder removal Pacemaker Defibrillator Hip surgery Hysterectomy Knee surgery LEEP (cervix surgery) Neck surgery Ovary removal Tubal Ligation Vasectomy Lung surgery Other surgical procedures/ Comments: Rev11/15

Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Review of Systems Name: Age: Date: Over the past few months, have you experienced any of the following symptoms? General Unexplained weight loss Unexplained fatigue Fever Chills Night sweats Skin New or change in mole Ears/ Nose/ Throat Difficulty swallowing Hoarseness Loss of hearing Genitourinary Blood in urine Frequent urination Neurological Headache Memory loss Fainting Numbness Tingling Breasts Lump Pain Respiratory Cough/ wheeze Loud snoring Altered breathing during sleep Shortness of breath with exertion Shortness of breath at rest Family History Gastrointestinal Heartburn/ reflux Change in bowel Movements Blood in stool Change in appetite Musculoskeletal Neck pain Back pain Cardiovascular Chest pain/ discomfort Irregular heartbeat Psychiatric Anxiety/ stress Irritability Please specify if any immediate family member has any of the following conditions or diseases: F- father M- mother B- brother S- sister MGF-maternal grandfather MGM- maternal grandmother PGF- paternal grandfather PGM- paternal grandmother Alcoholism Asthma Bleeding disorder Breast cancer Lung cancer Cancer- other Coronary artery disease Diabetes Heart attack Heart disease High blood pressure High cholesterol Kidney disease Mental illness Migraine headaches Thyroid disease Other/ Comments: Rev11/15

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