PATIENT INTAKE FORM DATE MAY WE THANK SOMEONE FOR THE REFERRAL? NAME PHONE HOW DID YOU HEAR ABOUT THE MIAMI BREAST CENTER? ARE YOU A COSMETIC PATIENT?
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1 Miami Breast Center Breast Surgery & Reconstruction Phone: Fax: PATIENT INTAKE FORM Welcome to the Miami Breast Center. Please take your time and carefully fill out this form. The information you provide will assist us in offering you personalized first class service. We are committed to ensuring that you are as comfortable as possible and have a positive and healing experience with us. DATE MAY WE THANK SOMEONE FOR THE REFERRAL? NAME HOW DID YOU HEAR ABOUT THE MIAMI BREAST CENTER? ARE YOU A COSMETIC PATIENT? ARE YOU A BREAST CANCER PATIENT AND HERE FOR RECONSTRUCTION? IF : HAVE YOU ALREADY HAD YOUR MASTECTOMY OR LUMPECTOMY? IF SO, WHEN: IF : WHEN ARE YOU SCHEDULED FOR SURGERY? NAME CELL HOME HOME WORK SEX MALE FEMALE EMERGENCY CONTACT DATE OF BIRTH RELATIONSHIP 1
2 INSURANCE INFORMATION PRIMARY INSURANCE ID # INSURANCE # GROUP # INSURED NAME SS# SECONDARY INSURANCE ID # INSURANCE # GROUP # HEALTH CARE PROVIDER PRIMARY CARE # CITY STATE (Breast Cancer Patients Will Fill Additional Information At Bottom Of Form) MEDICAL INFORMATION WHEN WAS YOUR LAST PHYSICAL EXAM? TEST WHEN FOR WHAT REASON? RESULTS BONE DENSITY DO YOU SMOKE? CT SCAN IF SO HOW MUCH? EKG MRI ULTRASOUND CHEST X-RAY MAMMOGRAM 2
3 MEDICATIONS / SUPPLEMENTS MEDICATION / SUPPLEMENT NAME HOW MANY DO YOU TAKE DAILY? REASON FOR TAKING MEDICATION / SUPPLEMENT ALLERGIES: Aspirin Iodine Penicillin Versed None Codeine Morphine Sulfa Valium Other PAST OR PRESENT MEDICAL PROBLEMS: Anemia Arthritis Asthma Cancer Cataracts Chronic Anxiety Frequent Urinary Infections Gallstones Glaucoma Chronic Cough Chronic Lung Disease Chronic Sinusitis Cirrhosis of Liver Colon Cancer Colon Polyps Diabetes Depression Paralysis Parkinson s Phlebitis Pneumonia Seizures Sexually Transmitted Disease Skin Cancer Stomach / Duodenal Ulcer Stroke TB (Tuberculosis) High Blood Pressure High Cholesterol High Triglycerides Irregular Heartbeat Kidney Disease / Failure Kidney Infection Polio Psoriasis Reflux Rheumatic Fever Kidney Stones Lupus Migraines Milk Intolerance Multiple Sclerosis Osteoporosis Pancreatitis Ovarian Cyst Diverticulitis Ear Infections Emphysema Fatty Liver Gout Groin Hernia Heart Attack Heart Murmur Hepatitis Hiatal Hernia SOCIAL HISTORY / MARITAL STATUS: Divorced Married Separated Single Widowed Do you have children? If so how many Have you ever breast fed? If yes how long? Other 3
4 SOCIAL HISTORY RECREATIONAL DRUGS: I have never used recreational drugs I have used recreational drugs in the past I am currently using recreational drugs I have been treated for substance abuse HEMATOLOGIC: Bleeding doesn t stop easily Frequent bruising Thrombosis / blood clots Transfusion Enlarged Glands Other SOCIAL HISTORY TOBACCO: I use tobacco products I quit using tobacco products I have never used tobacco products SOCIAL HISTORY AlCOHOL: Never Rarely Daily More than 2 days / week Less than 2 days / week I quit using alcohol ARE YOU CURRENTLY UNDER THE CARE OF A SPECIALIST (OTHER THAN BREAST CANCER)? NAME AND SPECIALTY? PAST MEDICAL HISTORY: Surgeries PROCEDURES YEAR PERFORMED Surgeries PROCEDURES YEAR PERFORMED Surgeries PROCEDURES YEAR PERFORMED 4
5 FAMILY HISTORY Mother Father Sibling RELATIVE AGE IF LIVING AGE IF DECEASED AILMENTS Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather BREAST CANCER PATIENTS FILL SECTION BELOW: ARE YOU CURRENTLY UNDER THE CARE OF AN ONCOLOGIST? HOME WORK DATE OF YOUR LAST EXAM? DIAGSIS ARE YOU CURRENTLY IN CHEMOTHERAPY TREATMENT IF : Please list chemo drugs: STARTING CHEMO DATE ENDING CHEMO DATE Have you had radiation: IF, DATES RADIATED: STARTING ENDING RADIATION DOCTOR INFORMATION: Are you scheduled for radiation START DATE END DATE 5
6 ARE YOU CURRENTLY UNDER THE CARE OF AN ONCOLOGY SURGEON? IF : HIPPA (PRIVACY PRACTICE FORM) WILL BE PROVIDED ON ARRIVAL TO THE OFFICE ALL PATIENTS PLEASE SIGN: SIGN DATE 6
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