CCCN Patient Questionnaire Date: Patient Name: Age: Referred by: Primary Care Physician: Please provide names and phone numbers of your physicians (primary care, medical oncologist, surgeon, etc.): Reason for visit: Please list problems that led you to seek medical attention here? Medical History Have you ever had chemotherapy? Yes No If so, provide date and place: Have you ever had radiation therapy, radiation implants, cobalt treatment, etc? Yes No If yes, please provide location, dates, and phone numbers of center where you were treated: Have you had any accidents or injuries of serious consequence? Yes No If yes, please list: Childhood Diseases: Previous Transfusion: Yes No If yes, did you have a reaction? Yes No 1
What was the reaction? Have you been in the hospital recently? Yes No If yes, when were you admitted (date)? Hospital? Reason for admission: Please check if you have a history of, or currently have any of the following: Arthritis Back Pain Yes No Yes No Pacemaker Pain: location Bronchitis mild moderate severe Congestive Heart Failure Diabetes Emphysema (COPD) Heart Attack Hepatitis B or C High Blood Pressure HIV Kidney Disease Liver Disease Lung Problems Other Heart Disease Previous Cancer Type Phlebitis Seizures Skin Disease Stomach Ulcers Thyroid Disease Tuberculosis Other (medical history not listed elsewhere): Surgery History Surgery Date Age Current Medications Medication Dose Frequency 2
Please list any drug allergies: Family History Family Member Father Mother Brothers Sisters Living/Age Deceased/Age Cause of Death List any Cancers List Other Medical Problems Any family members with cancer detected before age 50? Please list any other family members who have had cancer: Name/Age Relationship Cancer Type Social History Are you currently: employed retired unemployed on disability Occupation: Marital Status: single married divorced widowed separated Current Living Situation: alone spouse significant other friend parent child other Occupation of others in the household: 3
Children: # of sons ages any illness # of daughters ages any illness Have you ever smoked? Yes No If yes, what was your age when you started? Average packs per day: Date quit (if applicable): Do you drink alcohol? Yes No If yes, what type? How much per week? Did you ever drink large amounts of alcohol? Yes No Date quit (if applicable): Screening Exams Date of last mammogram: Results: Normal Abnormal Date of last bone density/osteoporosis scan: Results: Date of last Colonoscopy: Results: Normal Abnormal Other imaging studies (i.e. CT scan, MRI, PET): Where do you have your scan/imaging studies done? Prostate History (Men Only) Last PSA: Last prostate exam: Do you have impotence? Yes No Partial Total OB/GYN History (Women Only) Date of last menstrual period: Last pap smear: Are you currently pregnant? Could you be pregnant? # Pregnancies: # Live births Age at first pregnancy: Age of Menopause: History of birth control of hormone replacement? Yes No If yes, how long were you on the medication: Name of medication: 4
Review of Systems **Please mark only the symptoms you ve experienced within the last month** General Yes No Eyes Yes No Fatigue Fevers Night sweats Poor appetite Weight gain # pounds Weight loss # pounds Have you ever had a colonoscopy? Yes No Blurred vision Cataracts Double vision Glaucoma Floaters Vision Loss Cardiovascular Yes No Pulmonary System Yes No Ankle swelling Calf pain Chest pain Heart murmur Light headed feeling Palpitations Cough Coughing blood Pain with breathing Shortness of breath Sputum Wheezing Gastrointestinal Yes No Nervous System Yes No Abdominal pain Black stool Blood in stool Clay colored stool Constipation Diarrhea Difficulty swallowing Heartburn Nausea Vomiting blood Vomiting Yellow skin (Jaundice) Dizziness Headaches History of seizures History of stroke Loss of sensation Mental Illness Paralysis Passing out Speech disturbance Tremors Weakness of arm/leg If yes, when? Head and Neck Yes No Genitourinary System Yes No Difficulty swallowing Dry mouth Hearing loss Hoarse voice Mouth pain/ulcers Nose bleeds Post nasal drip Sinusitis/sinus pain Blood in the urine Frequent Urination Incontinence Night time urination Pain with urination Retention of urine Urgent Urination Date of last dental exam: How many times per night do you wake up from sleep to urinate? Musculoskeletal System Yes No Hematologic Yes No Arm or leg swelling Arthritis Back pain Bone pain Muscle pain Bruising Enlarged lymph nodes Gum or nose bleeding History of blood transfusion Treatment for anemia 5
Red or swollen joints Abnormal bleeding (with surgery) GYN Yes No Yes No Vaginal Bleeding Vaginal Discharge 6
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