RPA-CC-T-001.qxd



COMPREHENSIVE PATIENT MEDICAL HISTORY FORMMethodist Richardson Hematology Oncology AssociatesYour answers on this form will help your clinician understand your medical concerns and conditions. If you are uncomfortable with any question, do not answer it. Best estimates are fine if you cannot remember specific details or date. Thank you!PERSONAL INFORMATION:Preferred Name: DOB: Date: Current Health Concerns: MEDICATIONS: (Prescription and non-prescription medications, vitamins, birth control pills, herbs and supplements.)MEDICATIONDOSEFREQUENCYMEDICATIONDOSEFREQUENCYDrug Allergies or Reactions to Medications / Foods / Other Agents: # Yes # NoPlease list:PERSONAL MEDICAL HISTORY: Do you have any of the following?# Acid Reflux (heartburn)# Alcoholism# Allergies (environmental)# Anxiety# Asthma# Atrial Fibrillation# Cancer (list below)# Cholesterol Problem# Coagulation (bleeding) Problem# Chronic Low Back Pain# Depression# Diabetes# Erectile Dysfunction# Gout# High Blood Pressure# Heart Disease (explain below)# Migraines# Osteopenia / Osteoporosis# Prostate Problems# Thyroid Problems# Other Chronic or Recurring Medical Problems (Please list below)Patient Name: Date: PRIOR SURGERIES AND HOSPITALIZATIONS: # Yes # No(Please list all prior operations and hospitalizations)DATESURGERY OR HOSPITALIZATIONDATESURGERY OR HOSPITALIZATIONHave you received a blood transfusion? # Yes # NoWhen? FAMILY HISTORY: Please indicate with a check any family members who have had any of the following conditions: Check here if you don’t know your family history #MEDICAL CONDITIONM O MD A DB R OS I SD A U GS O NOTHER CLOSE RELATIVESMEDICAL CONDITIONM O MD A DB R OS I SD A U GS O NOTHER CLOSE RELATIVESAlcoholismGenetic DiseasesAnemiaGlaucomaAnesthesia ProblemAllergiesArthritisHigh CholesterolAsthmaHeart Disease (Heart attack, stent or bypass surgery)Birth DefectsHigh Blood PressureCancer, BreastKidney DiseaseCancer, ColonMigraine HeadachesCancer, MelanomaOsteoporosisCancer, Other SkinRheumatoid ArthritisCancer, OvarySeizuresCancer, ProstateStrokesCancer (other list below)Thyroid DisordersColon PolypsTuberculosisDepressionOther:Diabetes, Type 1Diabetes, Type 2COMPREHENSIVE PATIENT MEDICAL HISTORY FORMMethodist Richardson Hematology Oncology AssociatesPatient Name: Date: SOCIAL HISTORY:Tobacco UseAlcohol UsePlease check oneDo you drink alcohol? # Y # N# I have never smoked# never# occasionally# regularly# I have smoked, but rarelyAverage # drinks/week?5 oz. wine When was the last time? 12 oz. beer 1.5 oz. hard liquor # I have quit smoking. Quit Date: How many packs/day? How many yrs? # I currently smoke pack(s)/day.How many yrs. Is alcohol use a concern for you or others? # Y # NOther Tobacco: # pipe # cigar # snuff # chewDrug UseAre you interested in quitting? # Y # NDo you use recreational drugs?# Y # N Have you ever used needles?# Y # NSexual HistoryAre you sexually active? # Y # N # not currently Current sexual partner(s) is/are # male # female Birth control method: Have you ever had any sexually transmitted diseases (STD’s)? # Y # NDate: Which STD? Are you interested in being screened for sexually transmitted diseases? # Y # NExerciseDo you exercise? # Y # NHow often? # Daily # 4 – 6x a week # 1 – 3x a week # less than one time a weekWhat form of exercise? (e.g., jogging, cycling, swimming) SafetyDo you use seat belts consistently? # Y # N Is violence at home a concern for you? # Y # N Are you currently in a relationship? # Y # NIf yes, do you feel safe in this relationship? # Y # N other concerns? SocioeconomicsMarital Status: # single # married # separated # divorced # widowOccupation: Education completed: # grade school # high school # college # graduate schoolNumber of children: Who lives at home with you? Frequent foreign travel? # Y # NWhere? Patient Name: Date: Immunizations: Please check any immunizations you were given and your best estimate of the month and year it was given. Tetanus: # Y # N Pneumonia: # Y # N Chicken Pox: # Y # N Hepatitis A: # Y # N Hepatitis B: # Y # N HPV (genital warts): # Y # N Shingles: # Y # N REVIEW OF SYSTEMS (please circle any CURRENT problems you have on the list below)GeneralEyesGenitourinaryFatigue / WeaknessEye PainFrequent Urine InfectionsRestless SleepDouble Vision / Change in VisionPainful UrinationDaytime DrowsinessItchy / Watery EyesFrequent UrinationUnhappinessLungsUrinary Leakage / IncontinenceDepression / SadnessCough / WheezeBlood in UrineFeeling “Blue” or Hopeless for More than 2 wksSnoring / Gasping at Night During SleepOvernight Urination > 2 xLack of MotivationDifficulty BreathingSexual Function ProblemsExcessive IrritabilityPositive TB Skin TestMaleFeelings of WorthlessnessHeartDecrease in Force of UrinationNervous / AnxietyChest Pain / PressureErection ProblemsUnexplained Fever (> 100.0)Recent Change in Exercise ToleranceTesticle Lumps / SwellingFrequent Night SweatsHeart MurmurFemaleUnexplained Weight LossPalpitations / Irregular PulseVaginal Discharge / ItchingUnexplained Weight GainFainting SpellsHistory of Abnormal Pap SmearExcessive ThirstSwollen AnklesPain / Bleeding During SexSkinLeg Pain with Walking / ExerciseSignificant Pain / Cramps with MensesChanges in Moles / Unusual MolesGastrointestinalHot Flashes / Night SweatsConcerns re: skin spots / rashes / growthsAbdominal PainMenstrual HistoryBruise EasilyHeartburn / IndigestionAge of onset reg. / irreg. / menopauseItchingChange in Bowel Habits – RecentFlow: heavy / moderate / lightExcessive Hair GrowthDifficulty SwallowingLength of cycle Days of flow Hair LossPersistent Nausea / Vomiting# of pregnancies # of births Ears / Nose / ThroatDiarrhea / Constipation# of miscarriages / abortions Allergy SymptomsBloody or Black Tarry StoolsBreastHearing LossFrequent Laxative Use? How Often?Pain / Lumps / DischargeRinging in the EarsMusculoskeletalNeurologicalDizzy Spells / DizzinessMuscle / Joint PainFrequent HeadachesNose BleedsRecurrent or Chronic Back PainNumbness / TinglingSinus ProblemsJoint SwellingMemory LossHoarseness – FrequentGoutTremor / ShakingExplanation: ................
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