Department of General Surgery: Dr. Roshani Patel
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- Cynthia Sharp
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1 Department of General Surgery: Dr. Roshani Patel Name: Date: DOB: Family doctor: Ob/Gyn: Telephone number (best #): Are you interested in signing up for myd-h (communicating through your electronic Dartmouth chart with your providers?) Are there any questions that we may answer for today? Reason for visit: Currently, do you have any localized pain, a lump, or any other issues with your breast(s) or under your arm? If so, please mark the area in the diagram below: Breast Health History: Have you ever had or do you have: Breast pain Breast lumps Nipple discharge Cyst aspiration Breast Cancer Breast biopsy/surgery (lump removal, reduction, implant, mastopexy/mastectomy): If so list dates and facility that this was done and findings (if you know) in the table below: Procedure Date Facility
2 Cancer History: Have you had any personal history of other cancers: Have you had any prior chemotherapy or chest wall radiation? Family history of cancer (Especially Breast, Ovarian, Colon, Melanoma, Prostate, and Pancreatic Cancer) How many sisters do you have? How many sisters does your mother have? How many sisters does your father have? How many brothers do you have? How many brothers does your mother have? How many brothers does your father have? Relative: Mother or father s side (M or F) your sibling Cancer Type Age of Diagnosis Current age if alive Age at death if passed Has anyone in your family had genetic testing of any type? Relative Mother or father s side Result Gene Mutation (BRCA1, BRCA 2, Li Fraumeni, Cowden s Syndrome, Familial adenomatous polyposis(fap), Lynch,CDH1), HNPCC
3 Gynecological History Date of last mammogram: Bra Size: Age of first period: Date of last period: Age when first child was born: # of pregnancies: #Miscarriages: #Abortions: Have you ever taken birth control pills? If so, for how long? Age of menopause (if applicable): Did you take hormonal replacement: No Yes #of years Have you had a hysterectomy? If so, when? Have you had one or both of your ovaries removed? If so, when? Have you ever taken Tamoxifen or Raloxifene? Social History Smoking: Do you smoke or have you ever smoked? If so, how many packs a day? If you quit, when did you quit? Alcohol: Number of alcoholic beverages per week: Recreational Street Drugs: If ever used or currently being used, please list type and how often you are using the drug:
4 Review of Symptoms: Please review and circle any symptoms that CURRENTLY apply. General: fevers, sweats, chills, weight loss, excessive weakness, or fatigue Neurologic: tremors, focal neurologic symptoms, visual disturbances, headaches, fainting, blackout, paralysis, numbness or loss of sensation, tingling Psychiatric: nervousness, tension, depression, memory problems Eyes: blurry vision, glasses, pain, excessive tearing, spots, specks Ears: ringing in ears, dizziness, room spinning, earache, drainage from ear, hearing aids Nose/Sinus: nasal stuffiness, frequent colds, earache, infection, discharge Mouth/Throat: bleeding gums, sore throat, dry mouth, sores, hoarseness Neck: lumps, swollen glands, pain, stiffness, goiter Cardiac: heart trouble, heart murmur, chest pain, shortness of breath, shortness of breath when lying flat Respiratory: cough, sputum, wheezing Endocrine: heat/cold intolerance, excessive sweating, excessive thirst or hunger, excessive urination GI: constipation, diarrhea, indigestion, nausea, vomiting, abdominal pain, vomiting of blood Hematology: easy bruising or bleeding Vascular: leg pain, cramps, varicose veins, blood clots Kidney/Genitourinary: burning with urination, blood in urine, change in frequency of urination, incontinence, hernia, sores, rash, discharge, pain Extremities: muscle weakness, joint pain, stiffness, backache Skin: rash, jaundice, color changes, change in hair or nails
5 MEDICAL HISTORY Nervous System: Seizures Stroke Syncope Vascular Disease: Carotid Stenosis Peripheral Vascular Disease Bypass Procedures for Legs Blood Clot (Deep Vein Thrombosis) Heart Disease: Coronary Artery Disease Heart Attack Congestive Heart Failure Atrial Fibrillation Pacemaker Mitral Valve Disease Aortic Valve Disease Defibrillator High Blood Pressure Stent Placement Balloon Angioplasty Coronary Artery Bypass(Open Heart) Valve Replacement Diabetes Thyroid Disease Hepatitis A, B, or C HIV/AIDS Clotting Disorder Prior Blood Transfusion Reaction to prior blood transfusion Yes No Yes No Lung Disorders: Sleep Apnea Severe Asthma COPD Bronchitis Emphysema Tuberculosis Pneumonia Pulmonary Embolism(clot in lung) Joint: Arthritis Gout Vision: Glaucoma Cataracts Accidents Burns Autoimmune Disorders: Lupus Sarcoidosis Scleroderma Sjogrens MS Muscular Dystrophy Liver Disease Parasites Others (List): Kidney Disease: Kidney Failure Urinary Infections Kidney Stones
6 Are you taking any blood thinning medications such as Coumadin, Plavix, aspirin, ibuprofen, naproxen or any other blood thinners that may not be listed? Prior Surgeries: Date:
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