Initial History and Physical



Cape Fear Valley Cancer Center Ambulatory Summary ListThis form is to help your doctor give you better health care. It is completely confidential, and will be part of your medical record.NAME:Date of Birth: Home Phone ( ) Cell Phone ( ) Work Phone ( )Occupation:Retired? (circle one) Yes / NoPrimary Care Doctor:Doctor who referred you to us:Other Doctors to receive Oncology Treatment Notes if any:Pharmacy Name:Pharmacy Address:Pharmacy Phone ( )Emergency Contact Name: Home Phone ( )Relationship to you: Cell Phone ( ) Work Phone ( )Marital Status: (circle one) Married / Single / Widowed / Separated / DivorcedI live with: (circle one) Spouse / Significant Other / Alone / Family / Supervised Living / OtherMedical History (circle all that apply)No other medical problemsGI BleedingFibromyalgiaChicken Pox / ShinglesStomach ProblemsArthritisMeasles / Mumps / RubellaUlcerative Colitis/Crohn’sGoutHeart AttackGall Bladder ProblemsThyroid ProblemsHigh Blood PressureJaundice / Hepatitis / Liver ProblemDiabetes / Sugar ProblemsHeart MurmurKidney / Bladder ProblemsEczema / PsoriasisHigh CholesterolSexual ProblemsProstate ProblemsCongestive Heart FailureHIV / AidsBreast ProblemsPacemaker / DefibrillatorSeizure Disorder / ConvulsionsAnemia / Blood ProblemsStrokeNervous DisorderBlood TransfusionsAsthmaDepressionPrevious CancerEmphysema / COPDMental IllnessNonmedical Radiation ExposurePneumoniaDementiaOther: _______________Glaucoma HeadachesOther: _______________CataractsChronic PainOther: _______________For Women OnlyAge at onset of menstrual period: Date of last menstrual period: Is there a possibility that you are currently pregnant? Yes No NAEver taken birth control pills? Yes / No How long? _______ yearsNumber of pregnancies: Number of live births:Ever taken hormone replacement therapy? Yes / No How long? ________years Prior Surgeries or HospitalizationsMonth / YearOperation or HospitalizationPrior Cancer TreatmentsMonth / YearType of Chemotherapy or Radiation SiteAllergiesList all allergies: Food / Drug / Latex Reaction and SeverityMedicationsList all medications you currently take, or provide list to nurse:MedicationDoseTimes / dayMedicationDoseTimes / dayVitamins, Minerals, Herbs, SupplementsVitamin/mineral/herb/supplementDoseTimes per dayHabitsDo you use: (circle all that apply) Cigarettes / Cigars / Chewing Tobacco / SnuffNumber of years: _______ Quit date: _______ If cigarettes, packs per day: _______ Do you use alcohol: (circle one) Yes / NoNumber of Years: _______ Quit Date: _______ Drinks per Week: _______ Have you used recreational drugs: (circle one) Yes / NoPlease list family members with any type of cancer or blood disorder:Review of Symptoms (circle all that apply)ConstitutionalMusculoskeletalFeversTire easilyDifficulty walkingPainful legs / feetNight sweatsDifficulty standingBack pain / acheRecent weight loss # lbs _______ time frame ______Recent weight gain # lbs _______ time frame ______Difficulty liftingNeck pain / stiffnessJoint aches / stiffnessCardiologyRespiratoryChest painFeeling you might pass outShortness of breathCough producing bloodAnkle swelling Rapid/irregular heart beatDry coughCough producing sputumGastrointestinalGenitourinaryLoss of appetiteBlack/tarry stoolsPainful urinationUnable to control urineHeartburn / indigestionBloody stoolsDifficulty emptying bladderHaving to get up at night to urinateStomach pain/discomfortDiarrheaGas or crampsConstipationFrequent urinationBladder infectionsChanges in tasteNauseaBlood in urineVaginal itching / dischargeTrouble swallowingVomitingSexual problemsEyes, Ears, Nose, Throat, MouthNeurologicRecent vision changesHearing lossDifficulty concentratingDizzinessTooth painHearing aid(s)Numbness in hands / feetMemory changesOther dental problemsRinging in earsHeadachesHoarsenessEar painSore throatNosebleedsPsychosocial Distress ScreeningI am currently experiencing (circle number corresponding to your distress level): NoDistressExtremeDistress012345678910Please circle any of the items below that are causing distress:Practical ProblemsFamily ProblemsEmotional ProblemsSpiritual / ReligiousHousingDealing with partnerWorryAny concernsMoney / FinancialDealing with childrenFearsInsuranceDealing with otherSadnessWorkDepressionSchoolNervousnessTransportationLonelinessChild CareOther problems, things you would like us to know:Patient Name: ________________________Date of Birth: ________________________Medical Record Number: _______________ For Office / Nursing Use OnlyPhysician: HB SS IP TW SGD KB SM KM KF Consult Type: NEW R/CCancer Diagnosis: _______________________________Ht: ________ Wt: __________ T: ________ P:_______ R: ________ B/P: ________Patient Learns Best By: ReadingListeningDemonstrationPain:Y NLocation: _______________________________ Current Level: ________Worst(24 hrs): ________ Least(24 hrs):________Constant / Intermittent / BriefDescribe Pain: _________________________________________________________________What makes better: ____________________________ makes worse: _____________________Signature / Title:________________________Date: ______________Time:_______________Rev.10/12Revised: 8/13 mmc ................
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