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Transcription:

Dear Mercy Cancer Center Radiation Oncology Patient Welcome to our Department. In order to complete our records, and enable our physicians to ensure that your questions are fully addressed, we appreciate your efforts to complete this intake history form. If you feel any question does not apply to your case, please fill in N/A for not applicable. Name Address Date of Visit / / Date of Birth / / Do you have a DO NOT RESUSCITATE Advanced Directive? YES NO Do we have a copy? YES NO Doctor who signed order Who is accompanying you today? Your Diagnosis: When were you first diagnosed? Summary of your history Initial symptoms: Biopsy Date / Anatomic location of biopsy Scans, tests and procedures performed to date: CT: MRI: PET: XRAY: Labs: Treatment received to date (please include surgery and chemotherapy: Previous Radiation Therapy date, site treated: What facility? 1

Allergies: (Medication, food, environmental, tape, latex), and TYPE OF REACTION or can t recall. Allergy Reaction Circle Severity of Reaction Medications (prescription, over-the-counter, vitamins, herbal, hormones, chemotherapy): Medication Dose How Often Reason Taken Chemotherapy Drug: Date of last dose: Medical Oncologist: Height: ft. in. Weight: lb. T: P: R: B/P: O2Sat Preferred Pharmacy? Past Medical History previous and current medical problems, list approximate date of diagnosis: Past Surgical History approximate year of procedure: 2

Social History: Where were you born? What type of work did / do you do? Marital Status: SINGLE MARRIED DIVORCED WIDOWED With whom do you live? Do you have children? If yes, gender, ages, where they reside: Do you use tobacco products now or in the past? YES NO If yes: # of years # packs per day when quit Do you use recreational drugs? How much alcohol do you consume in a week Do you have a family history of cancer? If yes, please elaborate relationship and type of cancer: Relationship Type of Cancer NCCN Distress Thermometer for Patients: How distressed are you on a scale of 1 to 10? 10 Extreme 9 Frightening 8 Horrible 7 Awful 6 Dreadful 5 Really Bad 4 Uncomfortable 3 Bothersome 2 Annoying 1 Mild 0 No distress 3

Please circle the number that best describes how you feel right now? Review of Systems Pain Assessment Yes No Comments Pain Intensity-Current Scale of 1-10: Pain Location Pain Control Medications Constitutional Symptoms Yes No Comments Fever Weight Loss Loss of Appetite Fatigue Other Symptoms Eyes Yes No Comments Vision Changes Double Vision Blurry Vision Prescribed Eyewear Glasses Contacts Both Additional Notes: Eyes Ears, Nose, Mouth, Throat Yes No Comments Mouth Sores Trouble Swallowing Hoarseness Ear Pain Dentures Upper Full Partial Lower Full Partial Additional Notes: ENT Cardiovascular Yes No Comments High Blood Pressure Low Blood Pressure Chest Pain Heart Attack Pacemaker Defibrillator Implant Card Please provide for copy Stroke Edema/Swelling Location Additional Notes: Cardiovascular 4

Respiratory Yes No Comments Shortness of Breath Cough Cough-Productive Cough-Color Cough-Amount Sleep Apnea? C-Pap? OXYGEN USE? How much: How often: Gastrointestinal Yes No Comments Nausea Vomiting Diarrhea Constipation Blood in Stools Abdominal Pain Jaundice Additional Notes: GI Urination Yes No Comments Blood in Urine Burning with Urination Night time Urination How many times : Urgency Urinary Frequency Urinary Incontinence Additional Notes: GU Musculoskeletal Yes No Comments Bone Pain Arthritis Additional Notes: Musculoskeletal Skin Yes No Comments Skin Lesions/Lumps Sores Rash Surgical Incisions Breast Lumps Nipple Discharge Additional Notes: Integumentary 5

Neurologic Yes No Comments Headache Numbness/Weakness-Arms Numbness/Weakness-Legs Additional Notes: Neurologic Psychiatric Yes No Comments History of treated psych disease Additional Notes: Psychiatric Endocrine Yes No Comments Diabetes Diabetes controlled by: Thyroid problems Additional Notes: Endocrine Blood /Lymphatic Yes No Comments Bruising/Bleeding Large nodes Additional Notes: Hematologic/Lymphatic Allergic/Immunologic Yes No Comments History of Lupus History of Autoimmune Disease Scleroderma Rheumatoid Arthritis Collagen Vascular Disease Additional Notes: Allergic/Immunologic Gynecologic (Females) Comments Number of Pregnancies Number of Deliveries Vaginal Bleeding Yes No 1 st Menstrual Cycle Age Age: Menopause Age Age: Hormone Replacement Therapy Yes No Medication: Hormone Therapy Started --------- ---------- Date: Contraception: Medication Name/ Date Started Birth Control Pills Devices IUD release hormones Implants that release hormones (i.e. Nexplanon) Additional Notes: Gynecologic 6

AUA Prostate Cancer Assessment (American Urological Association) (Males) Please write down a frequency/score you experience for each symptom: Frequency of Occurrence Score Symptom Your Score Not at all 0 Sensation of bladder not empty Less than 1 time in 5 1 Urinate less than 2 hours after the last Less than half the time 2 Multiple stop/ starts when voiding About half the time 3 Difficult to postpone voiding More than half the time 4 Weak urinary stream Almost always 5 Push/ strain to begin urination Number of times per night up to urinate # Which doctors /care providers would you like to receive your records? (Family physician, medical oncologist, and surgeon)? Thank you for completing this form. Please let us know if we can be of assistance at any time. Mercy Cancer Center Radiation Oncology Physicians and Staff M: MTRA \Nursing \Nursing Documentation\ MCCRO New Intake Sheet. doc (5/2017) 7

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