SOUTH FLORIDA RADIATION ONCOLOGY HISTORY GENERAL - HISTORIA GENERAL PRELIMINARY PATIENT INFORMATION / INFORMACION PRELIMINARIA DEL PACIENTE

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1 SOUTH FLORIDA RADIATION ONCOLOGY HISTORY GENERAL - HISTORIA GENERAL PRELIMINARY PATIENT INFORMATION / INFORMACION PRELIMINARIA DEL PACIENTE Patient Name/Nombre delpaciente: Referring Doctor/Doctor que lo/la refirio: Primary Care Physician/Doctor de Cabecera: Other Physician(s)/Otros Doctor(es): Date of Birth/Fecha de Nacimiento: Age/Edad: Date/Fecha: Diagsis(If kwn)/diagstico(si es sabido): Reason for your visit today/razon por su visita hoy: How your problem was first discovered?/como fue su problema descubierto?: Were you having any symptoms that prompted a visit to your doctor?/tenia usted sintomas que le hizo visitar a su doctor? yes/si What were your symptoms if you had any?/si tuvo sintomas cuales fueron estos? Have you had a CAT scan or MRI of the area?/ha tenido un CAT escaner or IRM(resonancia magnetica) del area afectada? yes/si Have you had Mammogram?/Ha tenido una mamografia? yes/si Have you had a Bone Scan?/Ha tenido un escaner a los huesos? yes/si Have you had any X-rays?/Ha tenido alguna radiografia? yes/si Have you had an Ultrasound?/Ha tenido una Sografia? yes/si _ Have you had a PET scan?/ha tenido escaner PET? yes/si _

2 PAST MEDICAL HISTORY/HISTORIA MEDICA Heart Disease/Enfermedades Cardiacas yes/si High Blood Pressure/Pression Arterial Alta yes/si Diabetes yes/si Emphysema yes/si Asthma yes/si Bowel Disease/Problemas digestivos yes/si v Epilepsy/Epilepsia yes/si Gout/Gota yes/si High Cholesterol/Colesterol Alto yes/si Kidney Disease/Problemas Renales yes/si Liver Disease/Problemas de Higado yes/si Thyroid Disease/Problemas de Tiroides yes/si Depression/Depresion yes/si Arthritis/Artritis yes/si Anemia yes/si Ulcers/Ulcera yes/si Pacemaker/Marcapaso yes/si Polio yes/si Tinnitus/Tinnitus (Zumbido en los oidos) yes/si Glaucoma yes/si Bleeding Disorders/Problemas de Coagulacion yes/si Stroke/Derrame Cerebral yes/si Other Medical History/Otra historia medica Do you have a history of cancer in any other area of your body?/ha tenido cancer en otra parte de su cuerpo? yes/si If yes, Where? / Si ha tenido, donde? PAST SURGICAL HISTORY/HISTORIA QUIRURGICA When did you have your biopsy? / Cuando le hicieron la biopsia? Where did you have it done?/ Donde le hicieron la biopsia? What other surgeries have you had and in what year?/ Que otras cirugias ha tenido y en que a? Are you currently taking any medications?/ Esta tomando medicamentos? yes/si If yes, what are you taking? Si es asi, que medicamentos esta tomando? Are you allergic to any medications?/ Es alergico/a a algun medicamento? yes/si If yes, what?/ Si es asi, cuales? Si es asi, cuales?

3 Have you received any radiation therapy in the past?/ Ha tenido tratamiento de radioterapia antes? yes/si If yes, when/si es asi, cuando? and where?/ y donde? To what area of the body?/ A que parte del cuerpo? Have you received any chemotherapy?/ Ha recibido tratamiento de quimioterapia? yes/si If yes, when and for what reason?/ Si es asi, cuando y porque razon? SOCIAL HISTORY/HISTORIA SOCIAL Have you ever used tobacco products?/alguna vez ha fumado cigarillos? yes/si How much/when did you quit?/ Cuantos cigarillos diarios, por cuanto tiempo y cuando dejo de fumar? Do you drink alcohol?/ Bebe alcohol? yes/si If yes, how much?/ Si es asi, cuanto bebe? What was your past occupation?/ En que trabajaba o cual es su profesion? Have any of your family member been diagsed with cancer in the past?/alguien de su familia ha tenido cancer? yes/si If yes, who?/ Si es asi quien? Are you currently experiencing any of the following symptoms?/tiene algus de estos sintomas? Headaches/Dolores de cabeza yes/si Diarrhea/Diarrea yes/si Abdominal pain/dolor abdominal yes/si Constipation/Estrenimiento yes/si Dizziness/Mareos yes/si Blood in stool/sangre en las heces yes/si Nausea yes/si Dark tarry stool/heces negras oscuras yes/si Vomiting/Vomitos yes/si Gallbladder Disease/Problemas de Vesicula yes/si Difficulty Swallowing/Dificultad para Tragar yes/si Liver Disease/Problemas de Higado yes/si Hearing Loss/Perdida de la Audicion yes/si Fainting/Desmayos yes/si Hearing Aid/Audifos yes/si Fever/Fiebre yes/si Vision Loss/Perdida de la vision yes/si Forgetfulness/Olvidos yes/si

4 Wearing Glasses/Usa anteojos,espejuelos yes/si Loss of sleeping/dificultad al dormir yes/si Chest Pain/Dolor en el Pecho yes/si Indigestion yes/si Shortness of Breath/Dificultad para respirar yes/si Irregular heartbeat/palpitaciones irregulares yes/si Palpitations/Palpitaciones yes/si Low blood pressure/presion arterial baja yes/si Persistent Cough/Tos Persistente yes/si Poor circulation/mala circulacion yes/si Cough up blood/tos con sangre yes/si Rapid heartbeat/taquicardia yes/si Loss of appetite/perdida del apetito yes/si Double vision/vision doble yes/si Weight loss/perdida de peso yes/si Hoarseness/Ronquera yes/si Have you ever been diagsed with HIV?/Ha sido diagsticado/a con el virus VIH? yes/si Do you have pain, weakness or numbness in an extremity?/tiene dolor, debilidad o entumecimiento en las extremidades? yes/si. If yes, which one?/si es asi, cual? Pain Assessment Where is the pain?/donde tiene dolor? When did the pain start?/cuando le empezo el dolor? Is the pain the same as previous pain or something new?/este dolor que tiene es el mismo de antes o es u nuevo? Is the pain constant or intermittent?/el dolor es constante or intermitente? How long does the pain last?/por cuanto tiempo le dura el dolor? How long is the absence of pain?/cuanto tiempo es la ausencia de dolor? What type of pain is it? Burning, stabbing, dull, cramping, pulling, tearing, throbbing, tingling, aching, etc?/ Que tipo de dolor es? Quemante, punzante, constante, calambre, agudo, desgarrante, pulsante, hormigueo/cosquilleo? Is the pain deep or superficial?/el dolor es profundo o superficial? Can you describe if the pain feels like it originates from bone, muscle, organs or skin?/puede describer si el dolor origina de los huesos, musculos, orgas o la piel? Does the pain radiate or is it isolated to one specific area?/el dolor lo tiene en un solo lugar o se irradia a otras partes del cuerpo? What relieves de pain?/ Que le alivia el dolor?

5 What increases the pain?/que le incrementa el dolor? Is the pain associated with anything specific?food, activity?/ El dolor esta asociado con algo especifico? Comida, actividad? Are there any associated symptoms with the pain?/tiene sintomas asociados con el dolor? Looking at the scale below, where does your pain level fall?/ Lea la escala del dolor, que numero de la escala corresponde a su dolor? Patient Signature/Firma del Paciente: Date/Fecha:

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