Charleston Hematology Oncology Associates, PA
Charleston Hematology Oncology Associates, PAMedical HistoryPatient Name: ________________________ Date of Birth _________________________Family History(Please write in names)If Living:If Deceased:AgeHealthAge at DeathCause of DeathFatherMotherBrothers/Sisters(Circle Sex)MFMFMFMFMFSons/Daughters(Circle Sex)MFMFMFMFMFHusband/WifeCheck (?) if any you or blood relative has had any of the following:ConditionYouRelativeConditionYouRelativeYesNoYesNoRelation to youYesNoYesNoRelation to youAnemiaHeart AttackAngina PectorisHeart DiseaseArthritisHeart Disease (Rheumatic)AsthmaHepatitisBleeding TendencyHigh Blood PressureCancerInsanityColitisJaundiceCongenital Heart DiseaseKidney Disease DiabetesLeukemiaEmphysemaMigraineEpilepsyNervous BreakdownFrequent Kidney or Bladder InfectionsStomach UlcersFrequent Lung InfectionsStrokeGallbladder DiseaseSuicideGoiterThyroid Disease GoutTuberculosisHay FeverOtherSurgeries: Hospitalizations: (other than operation)YearName of SurgeryYearReason for Hospital StaySerious Injuries : (other than above)Diagnostic X-rays:YearType of InjuryYearType of X-raysImmunizations: (please give date given)Smallpox:______________Polio:______________Typhoid:______________Tetanus:______________Are you allergic to any medications or latex?Yes No If yes, please complete below.Name of Medication Reaction Name of your Family Doctor:__________________________________________________________________Medications: Check (?) the medications you are currently taking and write in the name of the medicine next to it.Antibiotics _______________________________________Iron or poor-blood medications ________________________Aspirin, Bufferin, Anacin, Tylenol, or similar products ______Laxatives _________________________________________Asthma or wheezing medicine_________________________Phenobarbital or barbiturates _________________________Blood pressure pills ________________________________Sleeping pills or tranquilizers _________________________Blood-thinners or Coumadin __________________________Stomach or digestive medicine________________________Cortisone, Prednisone ______________________________Thyroid medicine __________________________________Cough Medicine ___________________________________Vitamins__________________________________________Digitalis or heart medicine ___________________________Water pills, diuretics ________________________________Dilantin __________________________________________Weight-reducing pills _______________________________Hormone or birth control pills _________________________Other Drugs (list below):_____________________________Insulin or diabetic pills _______________________________Personal Habits:Check (?) if you use tobacco regularly:Cigarettes (# per day) ___________ or smokeless tobacco (times per day)______PipeCigars (# per day) __________ If you used tobacco in the past, how long did you use when did you quit:Check (?if you drink alcohol regularly:Hard Liquor 1 – 3 oz per dayOver 3 oz per dayBeer1 bottle per day2 bottles3 or more Wine1 glass per day2 glasses3 or moreDo you drink coffee? YesNo3 or more cupsDo you have difficulty sleeping? NeverSometimesOftenDo you awaken very early in the morning without apparent cause and find it difficult to fall asleep again? FrequentlyOccasionallyRarelyPLEASE ANSWER ALL QUESTIONSHave you had any of the following during the past three months? Circle correct answer:CONSTITUTIONALGood general health lately……………………..No YesRecent weight change………………………….No YesFever…………………………………………... No YesFatigue………………………………………… No YesHeadaches……………………………………... No YesEYESEye disease or injury…………………………..No YesWear glasses/contact lens……………………..No YesBlurred or double vision………………………No YesGlaucoma……………………………………...No YesENTHearing loss…………………………………...No YesRinging in the ears…………………………….No YesEaraches or drainage…………………………..No YesSinus problems………………………………...No YesNose bleeds……………………………………No YesMouth sores……………………………………No YesBleeding gums…………………………………No YesBad breath or bad taste………………………...No YesSore throat or voice change…………………….No YesSwollen glands in neck…………………………No YesCARDIOVASCULARHeart trouble……………………………………No YesChest pains……………………………………..No YesSudden heart beat changes……………………..No YesSwelling of feet, ankles or hands………………No YesRESPIRATORYFrequent coughing……………………………...No YesSpitting up blood……………………………….No YesShortness of breath……………………………..No YesAsthma or wheezing……………………………No YesGASTROINTESTINALLoss of appetite…………………………………No YesChange in bowel movements…………………..No YesNausea or vomiting…………………………….No YesFrequent diarrhea……………………………….No YesPainful bowel movements or constipation……..No YesBlood in stool…………………………………..No YesStomach pain……………………………………No YesGENITOURINARYFrequent urination………………………………No YesBurning or painful urination……………………No YesBlood in urine…………………………………..No YesChange of force of strain when urinating………No YesIncontinence or dribbling……………………….No YesKidney stones…………………………………..No YesSexual difficulty………………………………..No YesMale – testicle pain……………………………..No YesFemale – pain with periods……………………..No YesFemale – irregular periods………………………No YesFemale – vaginal discharge……………………..No YesFemale – # pregnancies _____ # miscarriages ______Female – date of last pap smear ___________________Female – findings of last pap smear ? Normal ? AbnormalMUSCULOSKELETALJoint pain……………….………………………No YesJoint stiffness or swelling………………………No YesWeakness of muscles or joints…………………No YesMuscle pain or cramps…………………………No YesBack pain……………………………………….No YesCold extremities………………………………...No YesDifficulty in walking……………………………No YesSKINRash or itching………………………………….No YesChange in skin color……………………………No YesChange in hair or nails………………………….No YesVaricose veins…………………………………..No YesBreast pain………………………………………No YesBreast lump……………………………………..No YesBreast discharge…………………………………No YesNEUROLOGICALFrequent or recurring headaches………………...No YesLight headed or dizzy…………………………...No YesConvulsions or seizures…………………………No YesNumbness or tingling sensations………………..No YesTremors…………………………………………No YesParalysis………………………………………...No YesStroke……………………………………………No YesHead injury………………………………………No YesPSYCHIATRICMemory loss or confusion………………………No YesNervousness…………………………………….No YesDepression………………………………………No YesSleep problems………………………………….No YesENDOCRINEGlandular or hormone problem…………………No YesThyroid disease…………………………………No YesDiabetes…………………………………………No YesExcessive thirst or urination……………………No YesHeat or cold intolerance………………………..No YesDry skin………………………………………...No YesChange in hat or glove size…………………….No YesHEMATOLOGIC/LYMPHATICSlow to heal after cuts………………………….No YesEasily bruise or bleed…………………………..No YesAnemia………………………………………….No YesPhlebitis…………………………………………No YesPast transfusion…………………………………No YesEnlarged glands…………………………………No YesALLERGIC/IMMUNOLOGICHistory of skin reaction or other adverse reactions to:Penicillin or other antibiotics………… No YesMorphine, Demerol or other narcotics..No YesNovocaine or other anesthetics……….No YesAspirin or other pain remedies……….No YesTetanus antitoxin or other serums……No YesIodine, methiolate or other antiseptic…No YesOther drugs/medications ______________________________Known food allergies _________________________________Patient Signature: _______________________ Physician Signature: _______________________ ................
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