Broward Oncology Associates, P.A. PATIENT INFORMATION

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Transcription:

NAME: BIRTHDATE: AGE: LOCAL ADDRESS (Street city state zip): HOME TELEPHONE# CELL # SOCIAL SECURITY #: - - SEX MARITAL STATUS WHAT IS YOUR HT? WHAT IS YOUR WT? EMPLOYER WORK# SPOUSE'S NAME SPOUSE'S EMPLOYER SPOUSE S WORK# PRIMARY LANGUAGE NEXT OF KIN PHONE RELATIONSHIP IN CASE OF EMERGENCY NOTIFY PHONE # RELATIONSHIP PRIMARY DOCTOR / REFERRING DOCTOR: (Please list each if not the same) DOCTOR'S ADDRESS/PHONE Page 1 of 6

INSURANCE INFORMATION: PERSON RESPONSIBLE FOR BILL: PRIMARY INSURANCE CO. NAME OF POLICY HOLDER POLICY NUMBER GROUP NUMBER OTHER INSURANCE COVERAGE (secondary) NAME OF POLICY HOLDER POLICY NUMBER GROUP NUMBER ******************************************************************** I authorize the release of any medical information/records necessary to process your insurance claims and/or as requested by my doctor. I hereby assume financial liability for all services rendered. Please list the family members or other persons, if any, whom we may inform about your general medical condition and your diagnosis including treatment, payment, and other general health care concerns. Patient Signature Spouse's signature Date Page 2 of 6

******PLEASE TO COMPLETE THE OTHER SIDE****** newptinfo.rev01 07 Page One PATIENT INFO CONT D (name) PERSONAL HISTORY: Please check if you have or had any of the following problem(s): General -- fevers chills sweats anorexia fatigue malaise weight loss functional status sleep > 8 hrs sleep < 8 hr Skin rash itching prior melanoma bleeding NONE Eyes blurring double vision irritation discharge eye pain cataracts surgery vision loss NONE Breasts mass (es) pain discharge prior biopsy NONE DATE LAST MAMMOGRAM NOT DONE PRIOR BREAST BIOPSY (S)? --- Respiratory/cardiac poor exercise tolerance dyspnea wheezing cough prior heart attack sputum production bloody cough edema chest pain cyanosis palpitations pain in leg (s) leg ulcers vertigo NONE LAST CHEST X-RAY NOT DONE Gastrointestinal nausea vomiting diarrhea constipation change in bowel habits abdominal pain blood in stool bright red blood per rectum jaundice prior kidney stones NONE LAST COLONOSCOPY NOT DONE Page 3 of 6

Genitourinary painful urination blood in urine discharge frequency PAP smear (date done) hesitancy nocturia incontinence genital sores impotence kidney stones sexual problems NONE still menstruating (if yes, # days) if no, date of last menses Musculoskeletal back pain joint pain joint swelling muscle cramps muscle weakness stiffness arthritis gout NONE LAST BONE SCAN LAST CT SCAN/MRI Neurologic seizure syncope stroke weakness spasms tremor involuntary movements abnormal gait in coordination pain change in sensation numbness of extremities incontinence NONE Psychiatric depression anxiety memory loss mental disturbance suicidal ideation hallucinations paranoia NONE Endocrine cold and/or heat intolerance excess or frequent urination tremor 10 lb weight gain or loss in the last month thyroid disease NONE Hem/Onc abnormal bruising bleeding enlarged lymph nodes anemia blood transfusions prior cancer prior blood clots? NONE LAST BLOOD TRANSFUSION -------- Page 4 of 6

Allergic reactions hives eczema hay fever persistent infections NONE newptinfo.rev01 07 Page Two PATIENT INFO CONT D (name) Personal History YES NO DATE HIV Tuberculosis Pneumonia Diabetes High Blood Pressure Blood Disease Heart Disease Liver Disease Neurologic Disorders MEDICATIONS - list all medications you are currently taking. Include ALL medications even those over the counter (OTC) Drug Name (Generic/Brand) Dosage Frequency Status Page 5 of 6

ALLERGIES - Broward Oncology Associates, P.A. PAST MEDICAL HISTORY - Please provide a complete history including all illnesses, in juries, hospitalizations, and operations. List all illnesses, injuries & operations (Please include date, hospital, treatment, and Physician) Family History - Please list all blood relatives with their current health status and any illnesses they have had or now have Blood Relatives Alive (age) State of health Illnesses Deceased (age) Cause of death Father Mother Brother(s) Sister(s) Children Social History - Please check the appropriate boxes and fill in the accurate amounts of standard portions Smoking Alcohol Caffeine Aspirin Misc Drugs * Current Previous Beer/Week: Coffee Tea Cola #per day: Vitamins #packs per day Liquor/Week: other #of years: Laxatives #of years Quit Wine/Week: Cups per day: other: Antacids Other: newptinfo.rev1 07 Page Three Page 6 of 6

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