New Patient Assessment Form Oncology

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1 Today s : New Patient Assessment Form Oncology Personal Information Patient Social Security No.: DOB: Age: Phone #: City: Zip: Place of Birth: Significant Other: Do you speak/read/understand English? YES NO Referring Physician: Specialty: Other physician s involved in your health care: Primary Care Physician: Past Medical History: Please list all major diseases, illnesses, and surgeries for which you have had or been treated: Illness of Diagnosis Please answer these questions: 1. Do you currently smoke? YES Amount per day: NO Number of years: 2. Have you ever smoked? YES Quit: NO 3. Do you drink alcohol? YES Amount per day: NO Quit: Beer Whiskey Wine 4. Do you use illicit drugs? YES NO 5. Have you exposed to the following: Asbestos Pesticides Agent Orange Radiation Benzene Heavy Metals Coal Dust 6. Do you have or have you been exposed to any of the following? Hepatitis Tuberculosis (TB) Shingles Chicken Pox (within the last three weeks) Others Page 1 of 3

2 List any medications or substances you are allergic to: Name of your Pharmacy / Drug Store: Phone No.: Please list all medications you are currently taking: Name of Medication Dose How Often Prescribing Physician Are you trying alternative methods to assist you to control your cancer? YES NO Do you have any first-degree relatives who have had cancer? Relative Type of Cancer Age when Diagnosed Are you in need of help at home? YES NO Who will be available to assist you? What is your highest level of education? Grade School High School College Post Graduate Is spirituality/religion important in your life? YES NO Since you have became ill, have you felt any of the following? Nervous Overwhelmed by emotion Depressed Difficulty with concentration Change in your sleep patterns Angry Have you noticed a difference your strength recently? (Please describe) Do you have pain? (Describe your pain) Location: Persistent or Intermittent: What makes the pain better? What make the pain worse? Are you taking any medication for pain? YES NO Please rate your pain by circling the number that best describes your pain at its worst in the past 24 hours (No Pain) (Pain as bad as you can imagine) Page 2 of 3

3 Have you lost any weight? YES NO How is your appetite? Female Patients: of Last Menstrual Period: of Last Pap Smear: of Last Mammogram: Are you pregnant? How many pregnancies have you had? How many children do you have? Additional Information Please list any information that you think would assist us in providing you the best possible care. Signature of Patient Printed Name of Patient OR Signature of Person Completing Form Printed Name of Person Completing Form Page 3 of 3

4 VICTORIA CANCER CARE CENTER Name SS# Address City State Zip Home Phone ( ) Cell Phone ( ) of Birth Sex Age Marital Status: Married single Widowed Divorced Race/ Ethnicity: White Black Hispanic Other Primary Physician Referred By Employer Phone ( ) Employer Address Spouse: Phone: of Birth: Age: SS# Spouse Employer: Employer Phone: Emergency Contact: ( Not Same Household) Name: Relation to Patient: Address: City State: Zip: Home Phone:( ) Work:( ) Cell:( ) PLEASE PROVIDE YOUR INSURANCE CARDS AND INFORMATION: Authorization for care, assignment of benefits, and release of information. I, the undersigned, by presenting for services, request and authorize evaluation, diagnosis treatment by my physician and /or his/her designee. I further agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature each time, and this signature will bind me as though I had personally signed them. I acknowledge that I am responsible for my copays and balances at the time of service. If I am delinquent on my payment on my account, I realize that services may be denied due to my failure to pay for services rendered. I acknowledge and understand that I am responsible for all of the charges/ services rendered to my family or me. Signed

5 Consent Form Conditions for Treatment I, authorize Victoria Cancer Care Center & any other contracted physician to provide care incident to all office visits. This includes routine diagnostic procedures and medical treatments that are deemed necessary by the doctor & such other assistants they may designate. This consent also authorizes the physician to administer treatment anesthetics, & perform procedures as deems necessary in my diagnosis & treatment. I am aware the practices of medicine are not an exact science and acknowledge no warranty, guarantee or assurance has been made by Victoria Cancer Care Center & any other contracted physician. Patient s Signature/ Responsible Party Signature Name of Patient/Responsible Party Relationship to Patient Photo In order to keep our patient s chart current and up to date we ask that you allow our staff to take a photo of you to keep in your chart. This photo will only be used to help identify you and can only be seen by the doctor and staff. I authorize my physician at Victoria Cancer Care Center to obtain a photo of me for medical purposes. Patient s Signature/ Responsible Party Signature MEDICAID ONLY Private Pay Agreement I understand Victoria Cancer Care Center is accepting me as a private pay patient for the period of 1 year, and I will be responsible for paying any services I receive. The provider will not file a claim to Medicaid for services provided to me. Patient s Signature/ Responsible Party Signature

6 NOTICE OF HEALTH INFORMATION PRACTICES ACKNOWLEDMENT ACT FORM Victoria Cancer Care Center By my signature below, I acknowledge that I have received the Notice of Health Information Practices of Victoria Cancer Care Center. I understand that the organization reserves the right to change their notice & practices prior to implementation will post changes in our office waiting room. I understand that I have the right to request restriction as to how my health information may be used or disclosed & that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken act ion in alliance there on. Name of Patient/ Representative Signature of Patient/Representative

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