MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM. Reason for Consultation: Physicians involved in your care:
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1 MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM Name: Date: Reason for Consultation: Physicians involved in your care: PAST MEDICAL HISTORY HEAD, EYES, EARS CARDIOVASCULAR DIGESTIVE Blurred Vision Chest Pain Abdominal Fluid Cataracts Bleeding Problems Cirrhosis of the Liver Double Vision Blood Clots Colitis Glasses/Contacts Blood Disorders Constipation Glaucoma Edema/Swelling Diarrhea Headaches/Migraines Heart Attack Difficulty Swallowing Hearing Aides Heart Murmur Feeding Tube Hearing Loss High Cholesterol Gas Ringing in the Ears High Blood Pressure GERD/Heart Burn Irregular Heart Rhythm Hemorrhoids NOSE, MOUTH & THROAT Mitral Valve Prolapse Hepatitis Dentures Palpitations Jaundice Tooth Loss Fast Heart Rate Nausea Nose Bleed Vascular Problems Rectal Bleeding Hoarseness Varicose Veins Ulcer Sinus Problems Vomiting Sore Throat Weight Changes RESPIRATORY VENOUS ACCESS DEVICE GENITO-URINARY Asthma Groshong Catheter Dialysis Chronic Bronchitis Power Port Painful Urination COPD PICC Line Erectile Dysfunction Cough Sub-Q Port Frequency Shortness of Breath Blood in Urine Emphysema Incontinence Pneumonia Kidney Stones Sleep Apnea Urinating at Night Tuberculosis History Prostate Enlargement Wheeze Sexually Transmitted Disease Testicular Swelling Urgency Urinary Tract Infection FEMALE REPRODUCTIVE Post Menopausal Bleeding Uterine Fibroids Vaginal Bleeding Vaginal Discharge ENDOCRINE Low Thyroid Hyperactive Thyroid Insulin Dependent Diabetes Non-Insulin Dependent Diabetes
2 MUSCULOSKELETAL Aids Used for Mobility Arthritis Fibromyalgia Gout Mobility Impairment Osteoarthritis Rheumatoid Arthritis NEUROLOGICAL CVA/Stroke Seizure Date of last seizure Numbness/Tingling Fainting Tremors Vertigo INTEGUMENTARY Connective Tissue Disorder Lymphedema Lupus Night Sweats Psoriasis/Eczema HEMATOLOGICAL Anemia Blood Transfusion Easy Bleeding/Bruising PSYCHOSOCIAL Anxiety Claustrophobia Depression Diagnosed Mental Illness Panic Attacks PERSONAL HISTORY OF CANCER Previous Radiation Treatment Previous Chemotherapy Allergies/Reactions None Known Current Medications, Dosages/Frequency (including Vitamins, Herbal or Alternative Medicines/Treatments) Name of Medication Dosage of Medication Frequency Medication Taken Previous Surgeries Date
3 Family Cancer History No Remarkable Family Cancer History Member Age Alive Age at Death Type of Cancer Father Mother Maternal Grandmother Paternal Grandmother Maternal Grandfather Paternal Grandfather Sisters Brothers Aunts Uncles Sons Daughters Other Medical Problems Gynecological History Age of First Period Age at First Pregnancy How many times have you been pregnant? Age at Menopause How many children do you have? Hormone Use? Yes No Could you be pregnant? Are you using any type of birth control? Yes- active Yes- occasional Yes- but quit Never Yes- active Yes- occasional Yes- but quit Never Tobacco Use # Years # Packs/day Years Quit Alcohol Use # Days/Week # Drinks/day Years Quit Personal History Living Will, Durable Power of Attorney for Healthcare? Yes No If no would you like information? Yes No Where do you live? Home Nursing Facility Assisted Living Do you live with a spouse or significant other? Yes No Do you work? Yes No Retired Type of Work Do you have adequate transportation Yes No
4 MOUNT CARMEL RADIATION THERAPY INITIAL SELF NUTRITION SCREENING Name: Date: PAST WEIGHT HISTORY Current Weight: pounds One month ago I weighed about pounds Current Height: feet inches Six months ago I weighed about pounds During the past two weeks my weight has: Decreased Increased Not Changed CURRENT FOOD INTAKE Compared to my normal food intake, I would rate my food intake during the past month as: Decreased Increased Not Changed I follow these dietary restrictions: (Such as Low Sodium, Low fat, Vegan, Diabetic) I take the following supplements: (Such as Boost, Ensure, any vitamins, minerals, or herbals) I am now taking: (Select any that apply) Regular food, same amounts Very little of anything Only Liquids Regular food but smaller amounts Little solid food, mostly soft Only Tube feedings CURRENT SYMPTOMS I have had the following concerns during the past two weeks: (Select any that apply) Poor appetite Swallowing problems Diarrhea Taste changes Nausea Dry Mouth Constipation Vomiting Smells bother me Mouth Soreness Feel full quickly CURRENT ACTIVITIES & FUNCTIONS Over the past month, I would generally rate my activity as: Normal with no limitations Not myself, but able to do fairly normal activities Not feeling up to most things and in bed less than ½ the day Able to do little activity and spend most of my day in bed
5 AUTHORIZATION FOR USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION I hereby authorize the USE & DISCLOSURE of any and all medical records (including but not limited to records of any substance abuse, psychiatric/mental health information or HIV/AIDS information) of: Printed Patient's Name: Phone: Patient's Birthdate: Social Security Number: Person/Organization Authorized to Release the information: Person/Organization Authorized to Receive Information: For the following dates of treatment (include specific description of information requested): For the purpose of: (Optional) Further Medical Care Insurance Billing Legal Reasons Self Other (Please Specify) I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be redisclosed to a third party and no longer protected by these regulations. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my treatment, payment or healthcare operations. I may inspect or copy any information used/disclosed under this authorization. This authorization and request is fully understood and is made voluntarily on my part. I release the above-named facility of any legal liability that may arise from the release of the information requested. Patient's Signature: Date: Guardian/Legal Representative Signature: Witness: Date: I understand that I may revoke this authorization at any time except to the extent that action based on this authorization has been taken. This authorization will expire automatically 60 days from the date on which it is signed. Cancellation of this authorization prior to the 60-day limit must be made in writing and sent to the Health Information Management Department at the appropriate site listed below: Mount Carmel West Mount Carmel East Mount Carmel St. Ann's Attn: HIM Dept. Attn: HIM Dept. Attn: HIM Dept. 793 W. State St E. Broad St. 500 S. Cleveland Ave Columbus, OH Columbus, OH Westerville, OH *DT0195* NAME DOB Mount Carmel, Columbus, Ohio Authorization for Use of Disclosure of Protected Health Information (Obetz) Patient Chart MR # FAN #
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