The Rehabilitation Institute Cancer Rehabilitation

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DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation STAR Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors names and addresses (primary care physician and oncology physicians and any other doctors whom you want to receive information about your rehabilitation): History of Present Illness: Date of first cancer diagnosis: Date: Type & Stage: Treatment for first cancer diagnosis (list what you have undergone, are curently undergoing, and what you expect to undergo in the future): Date of second cancer diagnosis or cancer recurrance and type and stage of cancer: Treatment for second cancer diagnosis or cancer recurrance (list what you have undergone, are curently undergoing, and what you expect to undergo in the future): List any problems you are having as a result of cancer treatment: Current Medications (list all medications including over the counter/supplements/vitamins): ergies to Medications (list all medication allergies and the type of reaction that you had): PAGE 1

PAGE 2 Past Medical History (list any medical conditions you have that you have not already described, e.g., diabetes, high blood pressure, etc.): Past Surgical History (list any surgeries you have had in the past, including the date): Social/Functional History (Describe your current work status and any limitations you have regarding work): Describe your current living situation (e.g. who do you live with, what kind of dwelling do you live in, etc.): Do you have children (if so, how old are they)?: Describe any limitations you have in your daily activities: Describe any limitations you have in tasks such as preparing meals, grocery shopping, yard work and other household chores: Describe any limitations you have in recreational activities: Describe your exercise regimen and any limitations you have regarding exercise: How much alcohol do you drink?: Do you smoke now or have you in the past? (please explain) Where do you get support? What are your rehabilitation goals? _ Family History: (list medical problems that run in your family and who they affect): Height: ft. in. Current Weight: lbs. Weight one year ago: lbs.

REVIEW OF SYSTEMS Check the box if you have or haver ever had any of these problems: Frequent fevers Congestive heart failure Gout Night sweats Bronchitis / pneumonia Rashes / eczema/ psoriasus Unexplained weight loss Chronic cough Skin growths / lesions / lumps Unexplained weight gain COPD / emphysema Difficulty healing Insomnia Snoring or sleep apnea Drainage from nipple Chronic fatigue Shortness of breath Fainting / dizziness Daytime sleepiness Frequent indigestion / reflux Tremors / shakes Wear glasses / contacts Nausea / vomiting Tingling / numbness Eye pain Hiatal hernia Muscle weakness Dry eyes Inguinal hernia Stroke / paralysis Excessive tearing Stomach ulcers Concussion / head injury Double vision Jaundice / liver disease Memory problems Blurred vision Hepatitis Personality changes Light sensitivity Hemorrhoids Headaches Glaucoma Blood in stool Seizures / epilepsy Hearing loss Bloating / excess gas Nervousness / anxiety Ringing in the ears Irritable bowel syndrome Addiction Sensitivity to noise Diverticulosis Depression Balance problems / vertigo Abdominal pain Suicidal thoughts Earaches / infections Constipation Panic disorder Sinus infections Diarrhea Claustrophobia Frequent colds / congestion Incontinence / dribble Victim of abuse Nose bleeds Decreased stream force Eating disorder Deviated septum Frequent urination Bipolar disorder Bleeding gums Difficulty / pain urinating Hallucinations Sore tongue Blood in urine ADD / ADHD Frequent sore throats Bladder or kidney infection Post-traumatic stress Mouth ulcers, bumps, lesions Kidney disease Psychiatric hospitalization Loss of taste or smell Kidney / bladder stones Heat or cold sensitivity Persistent hoarseness Neck pain Diabetes / high blood sugar Difficulty swallowing Mid back pain Low blood sugar High blood pressure Low back pain Heavy sweating Heart murmur Buttocks pain Thyroid disease Mitral valve prolapse Shoulder / arm / elbow / wrist / hand pain Obesity Palpitations / irregular heartbeat Hip / leg / knee / ankle / foot pain Abnormal menstrual cycle Leg cramps Muscle aches / spasms Decreased sex drive Swelling of feet or ankles Joint swelling / stiffness Anemia History of blood clots Broken bones Easy bruising Chest pain Joint dislocations Transfusion in the past History of heart attack Arthritis Family history of sickle cell HIV positive / AIDS Do you have significant fatigue? o Yes o No Do you have diminished energy? o Yes o No Do you have an increased need to rest, disproportionate to any recent change in activity level? o Yes o No PAGE 3

PAGE 4 VISUAL ANALOG SCALES FATIGUE SEVERITY (circle only ONE number per question) A. Rate how severe your fatigue is right now: B. Rate how severe your fatigue is on your worst day: C. Rate how severe your fatigue is on average: FACTIT-F (Version 4)* Below is a list of statements that other people with your illness have said are important. Please circle or mark one number per line to indicate your response as it applies to the past 7 days. PHYSICAL WELL-BEING GP1 I have a lack of energy... 0 1 2 3 4 GP2 I have nausea... 0 1 2 3 4 GP3 Because of my physical condition, I have trouble meeting the needs of my family... 0 1 2 3 4 GP4 I have pain... 0 1 2 3 4 GP5 I am bothered by side-effects of treatment... 0 1 2 3 4 GP6 I feel ill... 0 1 2 3 4 GP7 I am forced to spend time in bed... 0 1 2 3 4 SOCIAL / FAMILY WELL-BEING GS1 I feel close to my friends... 0 1 2 3 4 GS2 I get emotional support from my family... 0 1 2 3 4 GS3 I get support from my friends... 0 1 2 3 4 GS4 My family has accepted my illness... 0 1 2 3 4 GS5 I am satisfied with family communication about my illness... 0 1 2 3 4 GS6 I feel feel close to my partner (or the person who is my main support) 0 1 2 3 4 Q1 Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it please mark this box o and go to the next section... 0 1 2 3 4 GS7 I am satisfied with my sex life... 0 1 2 3 4

EMOTIONAL WELL-BEING GE1 I feel sad... 0 1 2 3 4 GE2 I am satisfied with how I am coping with my illness... 0 1 2 3 4 GE3 I am losing hope in the fight against my illness... 0 1 2 3 4 GE4 I feel nervous... 0 1 2 3 4 GE5 I worry about dying... 0 1 2 3 4 GE6 I worry that my condition will get worse... 0 1 2 3 4 FUNCTIONAL WELL-BEING GF1 I am able to work (include work at home)... 0 1 2 3 4 GF2 My work (include work at home) is fulfilling... 0 1 2 3 4 GF3 I am able to enjoy life... 0 1 2 3 4 GF4 I have accepted my illness... 0 1 2 3 4 GF5 I am sleeping well... 0 1 2 3 4 GF6 I am enjoying the things I usually do for fun... 0 1 2 3 4 GF7 I am content with the quality of my life right now... 0 1 2 3 4 ADDITIONAL CONCERNS HI7 I feel fatigued... 0 1 2 3 4 HI12 I feel weak all over... 0 1 2 3 4 An1 I feel listless ( washed out )... 0 1 2 3 4 An2 I feel tired... 0 1 2 3 4 An3 I have trouble starting things because I am tired... 0 1 2 3 4 An4 I have trouble finishing things because I am tired... 0 1 2 3 4 An5 I have energy... 0 1 2 3 4 An7 I am am able to do my usual activities... 0 1 2 3 4 An8 I need to sleep during the day... 0 1 2 3 4 An12 I am too tired to eat... 0 1 2 3 4 An14 I need help doing my usual activities... 0 1 2 3 4 An15 I am frustrated be being too tired to do the things I want to do... 0 1 2 3 4 An16 I have to limit my social activity because I am tired... 0 1 2 3 4 PAIN SEVERITY (circle only ONE number per question) A. Rate how severe your pain is right now: (No pain) B. Rate how severe your pain is on your worst day: C. Rate how severe your pain is on average: PAGE 5 NGMC FORM # 132-02620 (8/17/12)

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