Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:

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Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, www.coainc.cc Ph: 614.442.3130, Fax: 614.442.3145 Name (Last, First, Middle) Birth Date Age Social Security # Appointment Date / / - - / / Address City State Zip Code Home Phone Cell Phone Work Phone Email Address ( ) - ( ) - ( ) - - Person Completing This Form: Patient Other (Relationship to Patient): Emergency Contacts Relation Home Phone Cell Phone Work Phone 1 ( ) - ( ) - ( ) - Address: Email**: 2 ( ) - ( ) - ( ) - Address: Email**: **Email addresses will only be used for Columbus Oncology and Hematology to contact you if unable to reach by phone and in the case of an emergency. Email is not to be used for you to communicate with us under any circumstance. Referring Physician: Phone: ( ) - Fax: ( ) - Self Referred Family Doctor Specialist - Type: Specialist - Type: Specialist - Type: Name: Name: Name: Name: If anyone else personally referred you to our practice, who? Sex M, F Marital Status Employment Status S, M, Life Partner W, D, Separated Occupation: (current and previous) History of Chemical Exposure? Agents? When? Are you ALLERGIC to anything? Yes No Retired, Working, Disabled Religion: List all Medications/Allergies and describe your reaction CURRENT MEDICATIONS (Include prescription, over-the-counter and herbals): ** Please attach additional sheet or add to last page Name of Medication Dose How often taken Reason for medication Length of time taken Page 1 of 5......... Name:............................. Birth Date :..... /... /........

CURRENT MEDICAL HISTORY: What is your medical reason for coming to Columbus Oncology and Hematology Associates? Please give the history of your current problem: (when it started; symptoms; treatment) PAST MEDICAL HISTORY: Please check ALL previous illnesses and list additional conditions. Bleeding problems High blood pressure Stroke Seizure Heart problems Circulation problems Lung problems Diabetes Liver problems Thyroid problems Kidney/urine problems Psychological/Psychiatric problems Frequent infections HIV/AIDS Tuberculosis Please provide information below for the conditions you checked above and other conditions including hospitalizations: Past Surgeries (include type of surgery and date): Immunizations: Pneumonia vaccine N, Y Date: Influenza (Flu Shot): N, Y Date: Other SOCIAL HISTORY ALCOHOL HISTORY Do you drink alcoholic beverages regularly (at least 1 drink per month)? Yes currently Yes but Quit Never/rarely If answered yes to either above question, answer the following questions: Beverage Total # of Drinks per Day Total # of Drinks per Week Number of Years Beer, Wine, Liquor If you have quit drinking, how old were you when you quit? Years old TOBACCO HISTORY Have you ever smoked at least 100 cigarettes (5 packs) during your lifetime? Yes currently Yes but Quit No If Yes, When did you first start smoking cigarettes regularly? Age, If quit, how old were you? Age On average, how many packs do/did you smoke per day? / most packs per day Any Childhood and/or Second hand smoke exposure? If yes, number of years, about number of hours/day Use of any other tobacco products? Chewing Tobacco, Snuff or Dip, Pipes, Cigars, How much per day, years used ** Interested in Quitting any tobacco products Please ask for more information and options. RECREATIONAL DRUGS Have you ever used any recreational (street) drugs? Yes currently Yes but Quit No If Yes, What agents and how much? Page 2 of 5......... Name:............................. Birth Date :..... /... /........

FAMILY HISTORY: Are you Adopted? No, Yes Are you a Twin? No, Yes What type of twin? Identical, Fraternal Excluding yourself, how many of each of the following blood-related family members do you have? Brothers: Sisters: Sons: Daughters: Remember to include those who are no longer living. Include only full brothers or sisters. Complete the table below for each of your blood relatives who has had cancer or a bleeding or blood related problem.. If it is a grandparent, aunt or uncle, place in the box a ''F" if from your father's side or ''M'' if from your mother's side of the family. Name Relative Type F or M Year Born Still Living Age Died Type of Cancer or Blood Problem Age Diagnosed Screening and Sexual History: Colon screening : Yes, No Colonoscopy Sigmoidoscopy Annual hemocult Barium enema Date of test perform: Next Due Any Polyps? Yes, No Bone Density : Yes, No Date: Result: To be answered by WOMEN only: Mammogram: Yes, No, Date Result Pap Smear: Yes, No, Date Result Age of first menstrual period? Regular monthly menstrual periods? Yes, No, if no when last period Are you now on or have you ever taken birth control pills? Yes, No, When? How Long Have you ever used estrogen replacement therapy? Yes, No, When? How Long? Have you ever had a miscarriage? Yes, No, How many? What Term? When? To be answered by MEN only: Prostate screening: PSA : Result if known: Date? Exam : Date For cancer patients only: Please complete the TABLE below for my PRIOR cancer, radiation treatment, or chemotherapy that you may have had: Prior Cancers (before current illness): Don't know No Yes Year Kind of cancer or type of disease / condition Prior Radiation Treatment (not dental x-rays or for broken bones): Prior Chemotherapy Page 3 of 5......... Name:............................. Birth Date :..... /... /........

General Health Questions: *Attach additional sheets if needed or add to last page General Weight Loss? N, Y Decrease in appetite? N, Y Night sweats? N, Y Fatigue? N, Y Decrease in energy? N, Y Fever? N, Y If any yes, explain and other general complaints? Eyes and Ears Change in hearing? N, Y Ear pain? N, Y Change in vision? N, Y If any yes, explain and other seeing or hearing complaints? Head, Nose, and Throat Sinus infection/pain? N, Y Nasal Drainage? N, Y Throat pain? N, Y If any yes, explain and other head or necks complaints? Cardiovascular Nighttime Shortness of breath? N, Y Lower leg swelling? N, Y Chest pain? N, Y Decrease in ability to exert oneself? N, Y Able to lie flat? N, Y If any yes, explain and other heart complaints? Pulmonary Shortness of Breath? N, Y Blood in Sputum? N, Y Cough? N, Y If any yes, explain and other lung complaints? Gastrointestinal Difficulty swallowing food? N, Y Indigestion? N, Y Diarrhea? N, Y Vomiting? N, Y Nausea? N, Y Constipation? N, Y Abdominal Pain? N, Y Blood in stool? N, Y Black stool? N, Y If any yes, explain and other abdominal complaints? Genitourinary Blood in urine? N, Y Increase in need to urinate? N, Y Difficulty starting urination? N, Y Burning or pain with urination? If any yes, explain and other urination complaints? N, Y Increase in urination at night? N, Y Dribbling or unable to control urine? N, Y Hematologic Bleeding after surgery? N, Y Easy bruising/ bleeding? N, Y Lymph node or gland swelling? N, Y If any yes, explain and other hematologic complaints? Prior transfusion? N, Y Any history of blood clots? N, Y Nose bleeds, rectal bleeding or bleeding at other site? (specify) N, Y Neurologic Headaches, troublesome or frequent? N, Y Decrease in ability to walk? N, Y Seizures? N, Y If any yes, explain and other neurologic complaints? Numbness in hands and feet? N, Y Decrease in muscle strength N, Y Tingling in hands/ feet? N, Y Psychiatric Change in mood? N, Y Depression? N, Y Change in behavior with family/friends? N, Y If any yes, explain and other psychiatric complaints? Anxious? N, Y Memory loss? N, Y Change in ability to think? N, Y Endocrine Diabetes? N, Y Hypothyroidism? N, Y Hyperthyroidism? N, Y If any yes, explain and other endocrinology complaints? Skin Rashes? N, Y Infections? N, Y Ulcers or open sores? N, Y Yellow skin? N, Y If any yes, explain and other skin complaints? Page 4 of 5......... Name:............................. Birth Date :..... /... /........

Any additional comments, information, issues you would like to discuss or provide to us: Physician Notes: - Office use Only - By checking this box, I confirm that I have reviewed this form in its entirety. Physician Signature : Columbus Oncology and Hematology Associates 810 Suite A, Jasonway Ave, Columbus, OH 43214, Phone (614)442-3130, Fax:(614)442-3145 Page 5 of 5......... Name:............................. Birth Date :..... /... /........

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