_ I. Personal Information Date of Birth Age: Home Address: Home Phone: Cell Phone: Office Phone: Fax: E-Mail: II. Chief Complaint Please describe the major problem that brings you in today: Who referred you? III. History of Present Illness (To be completed by physician)
IV. Functional History How far can you walk before needing to stop? What causes you to stop walking (i.e., pain, fatigue, etc.)? Do you use a cane, walker, wheelchair or other mobility device? What type? Do you use a brace? What type? Do you have trouble with normal activities (i.e., bathing, dressing, cooking, or cleaning)? Do you have a home health assistant? How many hours per day? How many days per week? What kind of home to you live in (i.e., house, apartment, assisted living, other)? How many steps to enter your home? Any additional steps once inside? V. Pain History Please describe the location(s), onset, duration and characteristics of your pain: Please circle the number that best describes your pain: What medications are you CURRNTLY taking to control your pain? Medication Name: Dose: Frequency: What medications have you PREVIOUSLY tried to control your pain? Medication Name: Maximal Dose: Frequency:
VI. Care Information Please list complete name and address of physicians Oncologist: Radiation Oncologist): Surgical Oncologist: Primary Care Physician: Other Physician: Other Physician: Other Physician: Pharmacy: Address: Phone: Fax: City: State: Zip:
VII. Medical History Please list all your current and past medical conditions: Date: VIII. Surgical History Please list all the operations you have had: Date: IX. Allergies and Sensitivities Please list all: Medication/Food/Substance: Reaction: X. Family History Please list current age (or at death) and health issues of your blood-related family: Mother: Father: Children: Siblings: Other:
XI. Social History Occupation: Marital Status: Number of Children: Hobbies: Do you ever smoke cigarettes? If so, how many packs a day? At what age did you start? If applicable, at what age did you stop? Do you drink alcohol? If so, how much daily? At what age did you start? If applicable, at what age did you stop? Do you use recreational drugs? If so, what type and how often? At what age did you start? If applicable, at what age did you stop? Do you exercise? If so, what type and how often? Females: Are you or could you be pregnant? XII. Medications Please list the medications you are taking: Prescription Medication Name: Dose: Frequency: Over-the-counter Medication/Supplement Name: Dose: Frequency:
XIII. Review of Systems Do you currently have any of the following (check all that apply): Constitutional: Fever Chills Weight loss >5lbs Weight gain >5lbs Excessive fatigue Recent fall Eyes: Vision changes Blurry vision Infection Injury Glaucoma Cataract Wear glasses/contacts Ear, Nose, Mouth & Throat: Hearing aid(s) Hearing loss Ear pain Ringing in ears Nose bleeds Nasal congestion Sinus drainage Mouth pain Cardiovascular: Chest pain or angina High blood pressure Erratic blood pressure Irregular heartbeat Palpitations Heart murmur High cholesterol Respiratory: Asthma Emphysema Shortness of breathe Infection Bloody sputum Gastrointestinal: Nausea Vomiting Constipation Diarrhea Stool incontinence Ulcer Abdominal pain Changes in bowel habits Endocrine: Diabetes Thyroid disease Genitourinary: Urinary tract infection Painful urination Blood in urine Incontinence of urine Musculoskeletal: Bone metastases Bone fracture Joint swelling Joint redness Arm pain Leg pain Neck pain Back pain Neurological: Headache Memory problems Concentration problems Speech problems Swallowing problems Arm weakness Leg weakness Neck weakness Numbness Tingling Nerve pain Balance problems Psychiatric: Anxiety Depression Hematologic/Lymphatic Anemia Lymph node swelling Face swelling/lymphedema Breast swelling/lymphedema Arm swelling/lymphedema Leg swelling/lymphedema Allergic/Immunologic Autoimmune disease (i.e., lupus) Allergy Skin: Rash Itching Other: The information on this form is accurate to the best of my knowledge Patient signature Date completed
XIX. General Physical Examination (To be completed by physician) Vital Signs: Height: Weight: SA02: Blood Pressure: Pulse Respirations: Constitutional: The patient is well developed and well nourished, in no apparent distress. HEENT: Head is atraumatic and normocephalic. Eyes are clear without injection, conjunctival pallor, or jaundice. Nares appeared normal. Mouth is well hydrated and without lesions. Mucous membranes are moist. Posterior pharynx is clear of any exudate or lesions. Neck: Supple. No carotid bruits. No lymphadenopathy or thyromegaly. Cardiovascular: Regular rate and rhythm without murmurs, rubs, or gallops. Peripheral pulses present. Respiratory: Clear to auscultation and resonate to percussion. Good thoracic expansion is present. Gastrointestinal: Abdomen is soft, nontender, and nondistended. Bowel sounds are present. No hepatosplenomegaly is noted. Genitourinary: Normal external genitalia. Skin: No rashes or ulceration present. Breasts: No masses or gynecomastia identified. Hematologic/Lymphatic: No adenopathy or lymphedema identified. Musculoskeletal: Normal range of motion without discomfort, deformity, or restriction in the bilateral upper and lower extremities.
XX. Neurological Examination (To be completed by physician) Mental Status: The patient is alert and oriented x3. Language: Fluency: Comprehension: Repetition: Naming: Reading: Writing: Memory: Immediate: Short-term: Long-term: Calculations: Construction: Abstraction: Cranial Nerves: I: Normal olfaction II: Vision is intact with normal visual fields and acuity. Pupils are equal, round, and reactive to light and accommodation. III/IV/VI: Extraocular muscles are intact without nystagmus. V: Facial sensation is intact. Normal strength and contraction are present in temporalis, pterygoid, and masseter muscles without atrophy or tenderness to palpation. VII: Face symmetrical with normal strength. No ptosis is present. VIII: Normal gross hearing. IX/X: Oropharyngeal motor function is grossly normal. Gag reflex is present. No dysarthria is noted. XI: Normal strength in the trapezius and sternocleidomastoid muscles without atrophy or tenderness to palpation. XII: Tongue without deviation, atrophy, or fasciculations. Sensory Function: Light Touch: Normal throughout. Pain/Temperature: Normal throughout. Joint Position: Normal throughout. Vibration: Normal throughout. Motor Function: Gait: Normal; patient is able to walk on heels and toes. Tandem gait is normal. Coordination: Normal finger tapping, rapid alternating movements, finger-to-nose, and heel-to-shin testing. Involuntary Movements: None present. Pronator Drift: Not present. Bulk: No atrophy or fasciculations present. Tone: No spasticity present.
Strength Right Left (To be completed by physician) Shoulder abduction 5/5 5/5 Shoulder adduction 5/5 5/5 Shoulder internal rotation 5/5 5/5 Shoulder external rotation 5/5 5/5 Elbow flexion 5/5 5/5 Elbow extension 5/5 5/5 Wrist flexion 5/5 5/5 Wrist extension 5/5 5/5 Wrist pronation 5/5 5/5 Wrist supination 5/5 5/5 Hand Grip 5/5 5/5 Finger abduction 5/5 5/5 Finger adduction 5/5 5/5 Finger extension 5/5 5/5 Thumb abduction 5/5 5/5 Thumb adduction 5/5 5/5 Thumb opposition 5/5 5/5 Hip flexion 5/5 5/5 Hip extension 5/5 5/5 Hip abduction 5/5 5/5 Hip adduction 5/5 5/5 Knee extension 5/5 5/5 Knee flexion 5/5 5/5 Ankle dorsiflexion 5/5 5/5 Ankle plantarflexion 5/5 5/5 Ankle inversion 5/5 5/5 Ankle eversion 5/5 5/5 Great toe dorsiflexion 5/5 5/5 Reflexes Right Left Biceps +2 +2 Brachioradialis +2 +2 Triceps +2 +2 Hoffman sign absent absent Patella +2 +2 Medial hamstring +2 +2 Achilles +2 +2 Babinski sign absent absent Clonus absent absent