Please list any treatments you have previously had for current illness. (Physical Therapy, Surgery, Radiation, etc.)

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Transcription:

Date: Patient Name: D.O.B Last First M.I History of Present Illness: What is the reason for your visit? Date symptom started? Please list any treatments you have previously had for current illness. (Physical Therapy, Surgery, Radiation, etc.) Past Medical History: Illness Yes/No Illness Yes/No Angina/ Cardiac Arrhythmias Diabetes Asthma Elevated Cholesterol Bleeding Disorder Fibromylagia Blood Clots Thyroid Disease Bronchitis High Blood Pressure COPD Kidney Renal Disease Coronary Artery Disease Liver Disease/ Hepatitis Dementia/ Alzheimer s Other Past Surgical History: Have you had any previous surgical procedures? If so please explain: Surgical Procedure(s) Yes No Date Performed 1 P age

Medications: Please list all medications, including prescription, non-prescription, and other (including herbal) that you are currently taking. Please include dosage and frequency taken. Medication Dosage Frequency Allergies: Please list any allergies/adverse drug reactions: Social History: Marital Status: Occupation: Habits: Substance Alcohol Tobacco Caffeine Recreational Drugs Do you Use? Yes/No What type? How many/day? How long? If quit, when? Family History: Please list any family members with a history of cancer with relation and age. 2 P age

Review of Systems: Please check any problem you have had in the last six months: General: Chills Chills without fever Chills Fatigue Fever Intentional weight loss Low energy level Malaise Night sweats Sweats Weight gain Weight Loss Respiratory: Asthma Bronchitis Chest pain Chest pain (painful respiration) Cough Dyspnea Hemoptysis Pneumonia Head, Eyes, Ears, Nose, and Throat: Blurred vision Conjunctivitis Corrective lens Diplopia Excessive Lacrimation Eye Pain Impaired Vision Photophobia Visual Changes Congestion Dysphagia Earache Ear infection Epistaxis Circulatory System: Angina Calf swelling Chest pain, atypical Dyspnea on exertion Hypertension Hypotension Palpitation Peripheral edema Peripheral edema-upper extremity Digestive System: Abdominal Cramping Abdominal girth, increase Abdominal pain Anorexia Blood in Stools Change in bowel habits Constipation Diarrhea Distention Dysphagia Excessive thirst Fecal incontinence Heart Burn Skin: Change in nail appearance Change in pigmented lesion Dry skin Easy bleeding Easy bruising Itching without rash Non melanoma skin cancer h/o Photosensitivity Pruritus Rash 3 P age

Gingival Bleeding Hearing corrected by hearing aid Hearing Loss History of dental problems Nasal discharge Nasal Drip Nervous System: Blackout Confusion Diplopia Dizziness Drowsiness Falls Focal motor weakness Gait changes Headache Impaired cognitive function Involuntary movements Lethargy Hematologic Anemia Bleeding disorder Easy bruising Ecchymosis Epistaxis Excessive bleeding on tooth extraction Fatigue Frequent infections Gingival bleeding Petechiae Prolonged bleeding Musculoskeletal System: Arthralgias Back pain Bone pain Carpal tunnel syndrome Fracture Low back pain Lymphedema Muscle weakness Neck pain Neck/back trauma Sciatica Swollen joints Endocrine System: Cold Intolerance Diabetes Heat intolerance Hot flashes, menopausal Hot flashes, unrelated to menopause Increase sweating Malaise Polydipsia Polyuria Impaired dexterity Tremor Voice change 4 P age

Your pain: Pain Diagram and Visual Analog Scale Mark the areas with the symbols on the diagram that matches your pain. Include all areas. If your pain spreads out, draw and ( ) from where the pain starts. ACHING: XXXX NUMBNESS: **** PINS AND NEEDLES: 0000 BURNING: >>>> STABING: //// THROBBING: ++++ For each area of pain, put a number beside it that matches your pain. The scale below describe the number your pain 5 P age

Previous Imaging Studies: Test X-Ray CT MRI Bone Scan Other Date Preferred Pharmacy: Pharmacy Address Phone # Physicians: Referring MD: Physicians Phone/fax # Primary Care: Orthopedic Surgeon: Medical Oncologist: Other: Patient Signature Date 6 P age

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