Highlands Oncology Patient History

Highlands Oncology Patient History

Name (First and Last)

_________________________________________________________Today's Date:____________________

Date of Birth:_____________________

Referring Physician:_________________________________________________

o Male

o Female

Primary Care Physician:_________________________________________________

OB/Gyn Physician:_________________________________________________

Other Physicians:_________________________________________________

Reason for Today's Visit:_________________________________________________________________________________________

____________________________________________________________________________________________________________

Personal Medical History: Please check all that apply and include year of diagnosis

Year

Year

o Alcohol dependence

o Heart valve disease

o Anemia

o Hepatitis,Type__________

o Angina/chest pain

o High blood pressure

o Anxiety

o High cholesterol

o Asthma

o HIV/AIDS

o Blood disorder Type________

o Inflammatory bowel disease

o Cancer Type_________

o Kidney disease/renal failure,

o Cirrhosis, due to alcohol

Stage________

o Colostomy/ileostomy

o Neuropathy

o Coronary artery disease

o Organ transplant, Type _________

o Congestive heart disease/CHF

o Parkinson's disease

o Chronic obstructive pulmonary

o Paralysis

disease/COPD

o Pneumonia

o Depression

o Rheumatoid arthritis

o Diabetes Type__________

o Schizophrenia

o Dialysis

o Seizure disorder

o Drug dependence,

o Stroke

Drug name_______________

o Thyroid disease

o Emphysema

o Tuberculosis

o GERD

o Ulcer Type__________

o Heart arrhythmia

o Vertebral fractures

o Heart attack/MI

o Other_______________

Hospitalizations/Surgeries: Please list all hospitalizations and surgeries

Date 1.

Reason for Hospitalization or Type of Surgery

Where

Doctor

2.

3.

4.

5.

6.

7.

Previous Treatment for Cancer (if applicable) When, Where Radiation Therapy:______________________________________________________________________________________________

Chemotherapy:_________________________________________________________________________________________________

Hormone Therapy:_______________________________________________________________________________________________

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patienthistoryform updated 5/2017

Highlands Oncology Group Patient History

Name (First and Last)________________________________________________________ Date of Birth______________________

Immunizations: Please check previous immunizations received and include date of last vaccine if known.

Flu

o

o Hepatitis B

o Shingles

o Pneumonia

Medications: Please list current prescriptions and over-the-counter medications, as well as herbals, supplements and vitamins.

Medication 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Dosage

Frequency

Pharmacy Name and location___________________________________________________________________________

Allergies

Are you allergic to any medications? o Yes o No

If yes, please list the medications that you are allergic to and the type of reaction: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

Are you allergic to:

Contrast/IV dye for scans oYes o No

Latex:

oYes o No

Tape:

oYes o No

Vaccines:

oYes o No

If yes, please list the type of vaccine:______________________

Other allergies:

oYes o No

If yes, please list other allergies:__________________________________________________________________

Blood Transfusions

Have you ever had a blood transfusion? o Yes

If yes, did you have a reaction?

o Yes

Date of last blood transfusion: _______________

o No Reason:_______________________________________ o No

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patienthistoryform updated 5/2017

Highlands Oncology Group Patient History

Name (First and Last)________________________________________________________ Date of Birth______________________

Screenings

Last mammogram (female) Last PAP smear (female) Last colonoscopy or sigmoidoscopy Last bone density scan Other

Date

Social History

Living arrangement: o Single o Married o Partnered o With family o Separated o Divorced o Widowed o Care Facility

Number of pregnancies _____________

Number of children:______________

Occupation (previous if retired):________________________________________________________________ o Retired

Have you served in the military? o Yes

o No

If yes, dates of service ________________

Do you currently use tobacco products:

o Yes Number per day: o Cigarettes: _______ o Cigars:_________ o Pipe:_________o Chewing tobacco:_________

For how many years have you used the above tobacco product? _________________________

o No Have you ever used tobacco products in the past?

o Yes

o No

When did you quit? ___________ For how many years did you use tobacco products? ______________

How many servings of wine, beer or other alcoholic beverage(s) do you drink per day? _________Per week?__________

Do you have a history of alcoholism?

o Yes

o No

Have you used illegal drugs?

o Yes

o No

If yes, which ones?___________________________________________________________________________________

Do you use marijuana?

o Yes

o No

What do you do for exercise?_________________________How many times per week?____________________________

Do you have an Advance Directive, Living Will, or Power of Attorney? o Yes

o No

If you have one of these, please bring to your next appointment

Family history of cancer

Father Mother Brother Sister Son Daughter Grandfather Grandmother Uncle Aunt

Type of Cancer

Age at Diagnosis

Alive or Deceased

Page 3 of 4

patienthistoryform updated 5/2017

Highlands Oncology Group Patient History

Name (First and Last)________________________________________________________ Date of Birth______________________

Symptoms: Please check all that apply or None

Do you have pain? o Yes o No if yes, where? __________________ Intensity (1-10) __________________ Freqency: __________________

Constitutional: o Appetite o Good o Fair o Poor o Weight loss o Fatigue o Generalized weakness o Fever o Altered taste o Chills o Night sweats o Hot flashes o None

Eyes: o Glasses/contacts o Blurred vision o Double vision o Dry eyes o None

Ears, nose, mouth, throat: o Hearing loss o Ringing in ears o Nose bleeds o Sinus tenderness o Hoarseness o Sore throat o Bleeding gums o Mouth sores o Dry mouth o None

Cardiovalscular/Heart: o Chest pain o Irregular heartbeat o Swollen feet, ankle or hands o None

Resipratoty/Lungs: o Cough o Sputum or phlegm production o Coughing up blood o Shortness of breath o Wheezing o None

Gastrointestinal: o Nausea o Vomiting o Difficulty swallowing o Frequent heartburn o Abdominal pain o Diarrhea o Constipation o Black stools o Change in bowel habits o Hemorrhoids o None

Genitourinary: o Pain/burning with urination o Excessive nighttime urination o Slow starting or stopping o Urgency o Unable to hold urine o Blood in the urine o None

Gynecologic o Vaginal dryness o Vaginal bleeding o Vaginal discharge o Pelvic pain o None

Musculoskeletal: o Bone pain o Muscle pain o Joint pain o Swollen joints o Back pain o Limited range of motion o None

Endocrine: o Heat intolerance o Cold intolerance o Excessive sweating o Increased thirst o None

Neurological: o Headaches o Seizures o Poor coordination o Weakness of arms or legs o Paralysis o Termor o Numbness in arms or legs o Dizziness o None

Immunologic/Infections: o Severe allergic reactions o Frequent or severe infections o Pollen allergies/hay fever o None

Integumentary/Skin: o Rash o Itching o A sore that won't heal o Dry skin o None

Hematologic/Lymphatic: o Easy bruising o Abnormal bleeding o Enlarged lymph nodes o None

Psychiatric: o Anxiety o Depression o Trouble sleeping/insomnia o Memory loss o Confusion o None

Breasts o Breast mass o Breast tenderness o Nipple discharge o Breast skin changes o None

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patienthistoryform updated 5/2017

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