* * Patient Name: Date of Birth: Race: q CAUCASIAN q AFRICAN AMERICAN q HISPANIC q ASIAN

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Download "* * Patient Name: Date of Birth: Race: q CAUCASIAN q AFRICAN AMERICAN q HISPANIC q ASIAN"

Laurence Neal
5 years ago
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1 14 W. GORE STREET ORLANDO, FL PHONE FAX Date of Birth: Race: q CAUCASIAN q AFRICAN AMERICAN q HISPANIC q ASIAN Marital Status: q Married q Single q Widowed q Divorced q Seperated Employer: Address: Name of Spouse Phone Number: Address: Home Phone: Work Phone: Cell Phone: Person To Contact In Case of Emergency Relationship: Referring Physician: Phone Number: Referring Physician s specialty: Primary Care Physician: Primary Care Physician Phone: Oncology or Gynecologist physician: FORM Page 1 of 5 8/13

2 Reason for your visit (include symptoms and duration): ALLERGIES/ADVERSE REACTIONS q None q Adhesive Tape q Latex q Iodine/Shellfish Drug and Food Allergies (Include Reaction) MEDICATIONS (including vitamins, herbal supplements and over the counter) Medication Medication Strength Frequency PERSONAL MEDICAL HISTORY: Are you currently suffering from or have any prior history of q Yes q No Coronary Heart Disease q Yes q No Cancer q Yes q No Diabetes If YES, Please indicate type (s)/ of cancer: Age of diagnosis q Yes q No Gallbladder Disease q Yes q No High Blood Pressure q Yes q No Peptic Ulcer Disease q Yes q No Thyroid Disease q Yes q No Tuberculosis FORM Page 2 of 5 8/13

3 (PAGE 2) PERSONAL MEDICAL HISTORY (continued/: Are you currently suffering from or have any prior history of Constitutional Systems Skin & Breasts q Yes q No Fever q Yes q No Rash q Yes q No Chills q Yes q No Wound q Yes q No Weight Loss lbs q Yes q No Itching q Yes q No Weight Gain lbs q Yes q No Lesions q Yes q No Nodule ENT q Yes q No Breast Pain q Yes q No Sore Throat q Yes q No Breast Lump q Yes q No Hoarseness q Yes q No Nipple Discharge Resgiratoy q Yes q No Shortness of Breath q Yes q No Cough q Yes q No Sleeping Upright/Extra Pillows Cardiovascular q Yes q No Chest Pain q Yes q No Palpitations q Yes q No Lower Extremity Edema {Swelling) Gastrointestinal q Yes q No Abdominal Pain q Yes q No Abdominal Bloating q Yes q No Abdominal Cramps q Yes q No Nausea q Yes q No Vomiting q Yes q No Diarrhea q Yes q No Constipation q Yes q No Rectal Bleeding q Yes q No Melena {Black, tarry stools) q Yes q No Jaundice Musculoskeletal q Yes q No Diffuse Joint Pain q Yes q No Muscle Aches, general q Yes q No Back Pain q Yes q No Hematuria {Blood in Urine) Endocrine q Yes q No Hot Flashes q Yes q No Muscle Weakness Hematologic & Lymghatic q Yes q No Swollen Glands, Neck q Yes q No Easy Bleeding q Yes q No Easy Bruising q Yes q No Night Sweats Genitourinay (MALE) q Yes q No Dysuria {Painful Urination) q Yes q No Urinary Frequency q Yes q No Urinary Urgency q Yes q No Testicular Pain q Yes q No Pelvic Pain q Yes q No Hematuria {Blood in Urine) q Yes q No Nocturia {Get up at night to urinate) q Yes q No Hesitancy Genitourinaly (FEMALE) q Yes q No Dysuria {Painful Urination) q Yes q No Urinary Frequency q Yes q No Urinary Urgency q Yes q No Menstrual Pain q Yes q No Pelvic Pain Neurological q Yes q No Suspected Current Pregnancy q Yes q No Headache q Yes q No Confirmed Current Pregnancy q Yes q No Paresthesias {Tingling) If yes, weeks q Yes q No Seizure Other chronic illness? Please indicate FORM Page 3 of 5 8/13

4 (PAGE 3) PAST SURGICAL HISTORY (check all that apply, indicate date if known) q None q Heart Valve q Abdominoplasty q Hernia q Appendectomy q Hysterectomy q Bariatric Surgery q Lumpectomy q Bladder Surgery q Mastectomy q Bowel/Stomach Resection q Orthopedic/ Joints q Breast Biopsy q Pacemaker q Breast Implants q Para-thyroidectomy q Breast Reduction q Prostate Surgery/Resection q C-Section q Spinal Surgery q Cardiac Stents q Thyroidectomy q Colonoscopy q Tonsillectomy q Coronary Bypass q Tubal Ligation q Defibrillator q Other: q Endoscopy q Gallbladder FEMALES ONLY Age at first period First day of last menstrual period Are your periods regular? q Yes q No Are you taking hormones? q Yes q No Number of: Living children Pregnancies Abortions Miscarriages Age at first childbirth Did you breastfeed any of your children? q Yes q No FAMILY HISTORY Has any blood relative had any of the following? Check all that apply and list which family member. q Coronary Heart Disease q Peptic Ulcer q Diabetes q Thyroid Disease q Gallbladder Disease q Tuberculosis q High Blood Pressure q Cancer Relative (indicate maternal or paternal) Age at diagnosis (approximately) Cancer Type (breast, Ovarian, other) Father q Living q Deceased: Age at Death Mother q Living q Deceased: Age at Death of of FORM Page 4 of 5 8/13

5 (PAGE 4) SOCIAL HISTORY /HABITS What is your current occupation/job description Use of Alcohol: q Never q Rarely q Socially q Daily What kind? (liquor, beer, wine) Use of Tobacco: q Never q Previously but Quit q Daily packs per day Caffeine: q Rarely q Occasionallyr q Daily cups per day Have you (or anyone that lives in the same household as the patient) had any of the following: A history of MRSA or VRE infection? q No q Yes: Treated? Recent exposure to chicken pox, shingles, scabies or lice? q No q Yes: Any other infectious (contagious) disease? q No q Yes: When? TUBERCULOSIS (T.B.) SCREENING - Check the boxes below if the answer is YES. If the answer is NO, leave blank q Cough for longer than 2 weeks q History of T.B. or active T.B. (even if on meds) q Blood in the sputum q Jail in the past two years q Fever or night sweats q HIV positive q Recent unexplained weight loss of> I0 lbs q Homeless or living in a shelter q Recent exposure to T.B. q Foreign born (Asia, E. Europe, Latin America, Africa) ADVANCE DIRECTIVES- (COMPLETE ONLY IF OLDER THAN 18) Do you have a Healthcare Surrogate? q No q Yes Do you have a Living Will? q No q Yes Do you have it with you? q No q Yes Do you have it with you? q No q Yes Patient/ Legal Representative Signature Date Time Clinical Staff Signature Date Time INTERPRETER ONLY (Please Print) Name: Agency: Telephone: Language: FORM Page 5 of 5 8/13

PATIENT INFORMATION SSN AGE HEIGHT WEIGHT REFERRED BY

PATIENT INFORMATION SSN AGE HEIGHT WEIGHT REFERRED BY Page 1 of 5 PATIENT INFORMATION NAME ADDRESS TELEPHONE (Street) (City, State, ZIP) P Check your preferred contact number. q Home q Office q Mobile EMAIL SSN AGE HEIGHT WEIGHT GENDER q Male q Female DATE