NEW PATIENT HISTORY FORM

Transcription

1 Today s Date: (Please print. Thank you.) NEW PATIENT HISTORY FORM Patient Name: MRN# DOB: / / Age: Male Female SSN: Address: Phone: ( ) Cell Phone: ( ) City: State: Zip: Secondary Address: City: State:_ Zip:_ May we leave a message on your answering machine / voic ? Yes No Address: May we you? Yes No Preferred Language: Ethnicity/Race: White Hispanic/Latino Black/African American Native American Asian/Pacific Islander Other Primary Care Physician: Referring Physician (if different): Please list any additional Physicians you see: (Include Phone #): Phone #: Phone #: Phone #: Phone #: Phone #: Phone #: Emergency Contact Name: _ Relationship: Phone: ( ) Power of Attorney (if applicable): Relation to You: Living Will: Yes* No *Please provide a copy for your records

2 Patient Name: MRN# Reason For This Visit: Medical History: (Check the items that apply to you, currently or in the past) None Anemia Bleeding Disorder Blood Clots Blood Disorder Frequent infections HIV / AIDS Diabetes Thyroid Disease High Blood Pressure High Cholesterol Atrial Fibrillation Congestive Heart Failure Heart Attack-MI Heart Disease Rheumatic Fever Heartburn / Reflux Heart Murmur Irregular Heart Beat Peripheral Vascular Disease Asthma Chronic Lung (COPD) Pneumonia/Bronchitis TB (Tuberculosis) Sleep Apnea Colon Polyps Crohn s Disease Diverticulitis Irritable Bowel Syndrome Ulcerative Colitis Stomach Ulcers GERD/Heartburn Hiatal Hernia Gallstones Cirrhosis of Liver Hepatitis A/ B/ C Pancreatitis Kidney Stone Kidney Disease/Failure Freq. Urinary Tract Infections Enlarged prostate Lupus-Autoimmune Reynaud s Syndrome Rheumatoid Arthritis Osteoarthritis Chronic back pain Osteoporosis Fracture Stroke Neuropathy Parkinson s Disease Paralysis Seizures Migraines Shingles Glaucoma / Cataracts Hearing loss Cancer Leukemia Lymphoma Anxiety Depression Drug Use Problems with Anesthesia Details of Medical History: Cancer History: Type: Date diagnosed Treatment:(Type, Date, and location of treatment) Treating Physician:

3 Patient Name: MRN# Past Surgical History: (Please circle and date any of the surgeries and/or procedures that you have undergone) Coronary Bypass Date: Knee Replacement Date: Angioplasty Date: Rotator Cuff Repair Date: Pacemaker Date: Cataract Date: Cardiac Valve surgery Date: Gallbladder surgery Date: Hemorrhoidectomy Date: Hysterectomy Date: Prostate Operation Date: Prostatectomy Date: Hernia Repair Date: Appendectomy Date: Tonsillectomy Date: Hip Replacement Date: Mastectomy Date: Lumpectomy Date: Other Operations:_ Social History: Tobacco Use: (Present &/or Past): Never Smoked Quit smoking When? How many years did you smoke? yr(s) How many packs? /day Currently Smoke Cigarettes Pipe Cigars How many packs? /day How many years? Chewing Tobacco Alcohol History: (Present &/or Past): Non Drinker Beer number of bottles per Day Week Month Wine number of glasses per Day Week Month Liquor number of glasses per Day Week Month Are you: Employed/Self Employed Unemployed Retired Disabled (Former) Occupation: Name of Employer: Work Phone: ( ) Marital Status: Married Single Widowed Divorced Other Lives Alone Lives with Family Lives in Nursing Home Winter Resident Year Round Resident Children: Yes No Number Health Maintenance: Sigmoidoscopy / Colonoscopy: Yes No Date: Findings: Last Mammogram: Date: Last Bone Density: Date: Last Pelvic Exam: Date _ Influenza (Flu) Shot: Date : Pneumococcal Shot: Date : Last Shingles Shot: Date : Last EGD: Date: Family Medical History: Indicate any family members with cancer, blood disease or other disease Age Disease If deceased, cause of death Father: Mother: Siblings: In your opinion, are there any diseases that run in your family? Yes No Please list:

4 Patient Name: MRN# Review of Symptoms: (Please check any current symptoms you have.) General: Weight loss How much Over what time period Fevers Max temp Chills Night sweats Fatigue EYES: Wear Glasses/Contact Lenses Blurred Vision Double Vision Ears, Nose, Throat: Hard of hearing or deaf Ringing in Ears Enlarged lymph nodes Chronic sinus Problems Sore throat Mouth pain/sores CHANGES/DIFFICULTY IN: Taste Smell Voice CARDIOVASCULAR: Chest pain/angina Pectoris Palpitations/heart murmur Irregular heart beat Pressure RESPIRATORY: Chronic or Frequent Cough Bloody Sputum Shortness of Breath GASTROINTESTINAL: Difficult or painful swallowing Abdominal pain Nausea Vomiting Heartburn Indigestion Lump or sensation in throat Food sticking Bloating Belching Diarrhea Constipation Rectal bleeding Black or tarry stools Hidden blood in stool Excessive rectal gas/flatus Loss of stool/fecal accident Poor appetite Jaundice GENITOURINARY: Kidney Stones Pelvic Pain Incontinence Burning or pain on urination Blood in Urine Difficult urination Men: Prostate problems MUSCULOSKELATAL: Joint Pain/Arthritis Muscle or joint weakness Back Pain Bone Pain Muscle aches NEUROLOGICAL: Numbness, tingling Arm or leg weakness Light-Headed, dizzy, fainting spells Headache Tremors SKIN: Rashes or itching Change in skin color or moles Varicose veins Skin Cancer PSYCHIATRIC: Anxiety/Agitation Depression Crying for no reason Insomnia Alcoholism Drug Problem (Now/Past) HEMATOLOGIC: Easy bruising Gum or nose bleeding Blood transfusion in past Allergies/Immunology: History of chronic infections History of allergies ENDOCRINE: Heat or cold intolerance Excessive Skin Dryness Excessive thirst or urination Weight problem Hot flashes BREAST: Rashes or itching Change in skin color or moles Varicose veins Skin Cancer Gynecology: Age at start of menses Last menstrual period Breast pain/lump Breast discharge or rash Vaginal discharge Menstrual irregularity or abnormal bleeding

5 Patient Name: MRN# MEDICATION LIST Date: Name: Date of Birth:_ Your treatment can be affected by any medication that you take, and it is important that your physician has updated and correct information. Drug Allergies: List all medication allergies Medication: Reaction: Medication: Reaction: Medication: Reaction: Medication: Reaction: Are you allergic to: Iodine Latex Shellfish CT Scan Dye / IV Contrast Eggs Peanuts Other: Type of Reaction: Pharmacy / address / phone #: List all medications (including non-prescription) that you are currently taking. Medication Dose Frequency Ordering Physician

6 NEW PATIENT HISTORY FORM Patient Name: MRN# Primary Insurance Carrier: Name of primary policy holder: Policy holder s Date of Birth: Policy holder s SS#: Policy holder s employer: Policy holder s employer address: Policy holder s employer phone #: Does plan have prescription coverage? Yes No Secondary Insurance Carrier: Name of secondary policy holder: Policy holder s Date of Birth: Policy holder s SS#: Policy holder s employer: Policy holder s employer address: Policy holder s employer phone #: Does plan have prescription coverage? Yes No I certify that the information I have given today is to the best of my ability and as fully and accurately as possible. I will notify the doctor/staff to any changes or additions at subsequent visits. Signature: Date:

7 REQUEST FOR RELEASE OF RECORDS I,, request a copy of my complete medical record from the office of: Name and Address of Practitioner To be sent to Florida Cancer Specialists: Address, City State Zip Code Fax/Telephone Number I give permission to Fax my medical records to the above listed person, company or medical facility. I understand that my records will be sent via telephone communication. Provide office fax number It is my understanding that by signing this authorization for release of my records, I am giving permission for Florida Cancer Specialists to receive copies of any medical, psychiatric, AIDS, Aids Related syndromes, HIV Testing, Alcohol and/or drug abuse related information for the above listed person(s) or organization. I also understand that this authorization may be revoked at any time except to the extent action has been taken prior to revocation. This consent will expire ninety (90) days after the date below or sooner at my election. Print Patient Name Signature Patient, Parent, or Legal Guardian/Representative Witness Date Date Date