Department of Radiation Oncology FIRST TIME VISIT APPOINTMENT CHECKLIST Department of Radiation Oncology 200 Medical Plaza, Ste B265 Los Angeles, CA 90095 310-825-9775 1. Complete ALL important Patient Forms prior to showing up to your appointment. Bring in all these forms with you. a) Health Questionnaire b) Patient Assessment Form c) Referring Physician Form d) Medication Summary List 2. Bring in all your outside/external medical records and lab reports not taken in UCLA. It is very important that any medical records that are not at UCLA (imaging films/cds (MRI/PET CT), operative reports and pathology slides/reports,) be available for your physician consult. Please make arrangements to bring these in for your consultation, or have them mailed/faxed ahead of time (ATTN: Scheduling Staff). 3. Show up 30 minutes ahead of your scheduled appointment time. This will give you time to fill out other forms such as a medical self-reporting history and physical form. 4. Bring in Health insurance identification cards, esp. if changed since last appointment. 5. If you belong to an HMO, please bring the authorization form if available, or the confirmation number. 6. Bring a list of all your medications and list any allergies to medications that you may have. 7. If you have a pace-maker, please bring in your pace-maker identification card. 8. If you speak a foreign language, and need a translator, please let us know at least 24 hours in advance, so that we can request an interpreter. 9. Prepare a list of questions that you wish to ask the doctor. If you do this in advance, you will be less likely to forget something.
Affix Patient Label Here Patient Health Questionnaire Radiation Oncology Patient Name: Date of Birth Date: Reviewed on: (to be completed by staff) History of allergy or other adverse reaction: YES NO YES NO If yes explain: Antibiotics Drug Allergy Morphine or narcotics Known food allergy Aspirin or other pain meds Environmental allergies Iodine/IV Contrast dye Medical History (please list past and current conditions): Medical Problems Surgeries Medications See Reconciliation Medication Sheet Have you ever had: YES NO YES NO Lupus Inflammatory Bowel Disease Scleroderma Crohn s Disease Ulcerative Colitis Previous Radiation Therapy Do you have a Pacemaker Previous Chemotherapy Gynecological (female patients only): Date of first day of last period Age periods first started Number of pregnancies? Number of children: Number of miscarriages: Age at first live birth? Is there a possibility you may be pregnant Have you ever taken hormone replacement medication? If yes, what type Date of last Mammogram: List any other tests: Date of last Pap Smear? YES NO Breast History: Please check the correct answer YES NO RIGHT LEFT HOW LONG? Do you have any lumps in your breasts? Do you have breast pain? Do you have nipple discharge? FAMILY HISTORY: If Living: Age Father Mother Brother/ Sister If Deceased: Age (at death) Cause Have any of your immediate relatives ever had cancer? If Yes, please list type of cancer?
SOCIAL HISTORY: Marital Status: Single Married Domestic Partner Separated Divorced Widow How often do you drink alcohol? Never Rarely Moderately Daily YES NO Do you smoke tobacco? If yes, how long Did you ever smoke tobacco? If yes, how many years did you smoke Are you employed? If yes, what is your occupation Would transportation to UCLA for daily treatments be difficult for you? YES NO If Yes, please explain: System Review: Please check yes or no box to indicate if you have any of the following symptoms General Fevers Night Sweats Chills Recent Weight change If yes, lbs Eyes Eye Disease or injury Do you wear glasses Change in vision Ears, Nose & Throat Change in hearing Voice change Sore throat Respiratory Shortness of breath Cough Wheezing Cardiovascular Chest Pain Shortness of breath while walking or lying down Difficulty walking two blocks Swelling of hands, feet or ankles Heart Murmur Irregular heart beat Gastrointestinal Bleeding with bowel movements Black stool Recent change in bowel habits Frequent diarrhea Heartburn or indigestion Constipation Genitourinary Frequent urination Night time urination Burning or painful urination Blood in urine Sexual Difficulty Incontinence YES NO YES NO Musculoskeletal Joint Pain Joint Swelling Injuries or Joint Fractures Back Pain Skin Hives Eczema Rash Abnormal pigmentation Neurological Fainting spells Convulsions Paralysis Headaches Psychiatric Depression Anxiety Memory Loss or Confusion Insomnia Endocrine Excessive thirst Intolerance to heat/cold Hematologic Anemia Have you had abnormal bruising or bleeding Swollen glands Immunology/Allergy Allergies to animals or plants Runny Nose Itchy Eyes The Past Medical History, Family History, Social History, and Review of Symptoms is reviewed with the patient by the physician(s) noted below: Resident Signature Date Attending Physician Signature Date 5-28-08 Revised Health Questionnaire
Please affix patient label here Referring Physician Information Please list the names and phone numbers for all of your referring physicians. Communicating with each of your physicians is an important part of our care. Examples: Medical Oncologists, Primary Care Physician, etc. Physician Name: Phone No. Address: Fax No. Specialty Physician Name: Phone No. Address: Fax No. Specialty Physician Name: Phone No. Address: Fax No. Specialty Physician Name: Phone No. Address: Fax No. Specialty Rev. 03/10
Please list 4 persons who we may contact in case of emergencies or for follow-up in case we lose contact: 1. Name Relationship Address City/State Zip Code Phone # Email 2. Name Relationship Address City/State Zip Code Phone # Email 3. Name Relationship Address City/State Zip Code Phone # Email 4. Name Relationship Address City/State Zip Code Phone # Email
U C L A Medical Center AMBULATORY SERVICES PROBLEM SUMMARY LIST REVIEWED DATE/ INITIALS ALLERGIES ADVANCE DIRECTIVE No Yes, List No Yes, Disposition Drug, including overthe counter and herbal preparation MEDICATION RECONCILIATION Dose Route Frequency Reconciliation: D/C = Discontinued = Changed Date/ Initials PRINT NAME AND INITIALS Rev. 1/28/2009-AG