Microsoft word - gresik new patient intake form.docx

DR. CHRISTINE M. GRESIK
ELMHURST MEMORIAL HEMATOLOGY & ONCOLOGY ASSOCIATES
NEW PATIENT MEDICAL HISTORY
DATE: ______/______/______
NAME (LAST, FIRST, MI):_____________________________________ Sex: r Female r Male

Date of Birth: _____/_____/_____ Age: ______
Marital Status: r Single r Married (how long) ________ r Divorced r Separated r Widowed
Home Address: _________________________________________________________________________________________________________
Home Phone: (_____)________________________
Employer/Business Name: ____________________________________________________ Occupation: ________________________________
Emergency contact: __________________________________________________ Relationship: ________________________________________
Address _________________________________________________________________________ Phone: (_____)________________________
Referring Physicians:
1. Name: ________________________________________________________________________ Phone: (_____)________________________
Address: ____________________________________________________________________________________________________________
Other Physician(s):
2. Name: ________________________________________________________________________ Phone: (_____)________________________
Address: ____________________________________________________________________________________________________________
3. Name: ________________________________________________________________________ Phone: (_____)_________________________
Address:____________________________________________________________________________________________________________ Periodic reports may be sent to your Physicians. To which of the above would you like these reports sent? 1. ____________________________________ 2. ____________________________________ 3. _____________________________________ Please describe briefly, in your own words, the date of
onset of your current problem or illness, any
symptoms you have experienced, and the dates of any
test and/or treatment(s).
_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ (STAFF USE ONLY)
_______________________________________________
REASON FOR SEEKING CARE

1. Have you been diagnosed with breast cancer recently or are you here to seek treatment for breast cancer?

2. What was the very FIRST problem that occurred which prompted you to seek medical care? Check one.

r lump in breast, don’t recall who found it r other (please specify _______________________________________) r armpit or axil ary mass

At approximately what date did this symptom (including abnormal mammogram) become apparent to you?
3. Were there any other problems? Check all that apply.
r lump in breast, don’t recall who found it r other (please specify _______________________________________)
GYNECOLOGIC HISTORY
4. At what age did you have your first period? 5. How many times have you been pregnant? 10. a. If you have children, what was your age at your first time full term pregnancy? b. If you have children, what was your age when you had your last full term pregnancy? 12. a. Have you ever breast fed? r Yes r No (skip to question 13) b. If yes, how many months (in total) have you breast fed? c. If yes, how many years (or months) ago did you last breast feed? (please circle one)
13. Have you had a menstrual period within the last six months? r No r Yes, natural menstrual periods or menstrual periods on birth control pil s (answer question 14, then skip to question 18) r Yes, menstrual periods on hormone replacement therapy (answer question 14, then skip to question 18) r Unknown 14. When was your last menstrual period? _____/______/_____ 15. If you have NOT had a menstrual period within the past 6 months, why did your periods stop? Check one.
r both ovaries removed, no hysterectomy r chemotherapy/radiation therapy/hormone therapy r medical condition(s) associated with ovarian failure r hysterectomy with both ovaries removed r hormone replacement therapy (not including HRT for cancer therapy) r other (please specify ______________________________________) 16. If you have not had a period within the past 6 months, at what age did you stop having periods? OR, if both ovaries have been removed, at what age were they removed? 17. If both ovaries have been removed, what was the date of surgery (month/year)?
18. Have you ever used, or do you currently use, ‘post-menopausal’ hormone replacement therapy? Do NOT include birth control pills.
r No, never (skip to question 21) r Yes, currently When did you start therapy (month/year)? When did you last use hormones (month/year)?
19. If you use hormones currently or in the past, what form(s) of hormones do/did you use? Check ALL that apply.
r combination estrogen and progesterone 20. How many total years (or months) have you used hormone replacement? (please circle one)
21. a. Do you use, or have you ever used, birth control pil s? r No, never (skip to question 22) r Yes, currently r Yes, in the past When did you last use birth control pil s (month/year)? b. How many total years (or months) have you used birth control pil s? (please circle one)
r Yes r No (skip to question 23) a. If yes, have you used Clomiphene citrate (i.e. Serophene, Clomid)? r Yes r No r Do not know b. If yes, have you used an injectable hormone (i.e. hMG, Gonal-F, Fol itism)? r Yes r No r Do not know SMOKING AND ALCOHOL HISTORY
23. Have you ever or do you currently smoke? a. If yes, at what age did you start smoking? r No, never (skip to question 25) b. If yes, at what age did you stop smoking? 24. If you have ever smoked, on average, how many packs per day did you smoke, or do you currently smoke? Check one.
25. Have you ever or do you currently drink alcohol? r Yes, but only in the past r Yes, currently r No, never (skip to question 27) 26. How many alcoholic beverages (beer, wine, mixed drinks, etc.) do you consume weekly? Check one.
PHYSICAL ACTIVITY
27. Which option below best describes your level of physical activity OVER THE PAST WEEK? Check one.
r fully active, able to carry on all usual activities without restriction r restricted in strenuous activity; can walk; able to carry out light housework r can walk and take care of self; up more than ½ day r need some help in taking care of self, spend more than ½ day in bed or chair r cannot take care of self at all and spend all my time in bed/chair
MEDICAL HISTORY
28. Do you currently have, or have you ever had any of the following? Been treated for heart failure? (You may have been short of breath and the doctor may have told you that you had fluid in your lungs or that your heart was not pumping wel ) An operation to unclog or bypass the arteries in your legs? A stroke, cerebrovascular accident (CVA), blood clot or bleeding in the brain, or transient ischemic If yes, do you have difficulty moving an arm or leg as a result of a stroke or cerebrovascular r Yes r No r Don’t know accident? Asthma, emphysema, chronic bronchitis, or chronic obstructive lung disease (COPD)? If yes, do you take medicine for your condition (either on a regular basis or just for flare-ups)? Stomach ulcers or peptic ulcer disease (PUD)? If yes, was this condition diagnosed by endoscopy (where a doctor looks into your stomach through a scope), or an upper GI or barium swal ow study (where you swal ow chalky dye a. If yes, is it treated by modifying your diet? b. If yes, is it treated by medications taken by mouth? c. If yes, is it treated by insulin injections? d. Has your diabetes caused problems with your kidneys, or problems with your eyes a. If yes, have you had poor kidney function with blood tests showing high creatinine b. Have you used hemodialysis or peritoneal dialysis? c. Have you received a kidney transplant? If yes, do you take medications for it regularly? Alzheimer’s Disease, or another form of dementia? Cancer (other than breast cancer, skin cancer, leukemia or lymphoma)?
If yes, has the cancer spread, or metastasized, to other parts of your body? MEDICATIONS
29. Please list any medications you are now taking (include name, dosage, and frequency): ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ALLERGIES
30. a. Are you al ergic to any medicines? r Yes r No *If so, please list any medications to which you have had an al ergic reaction, and the type of reaction: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ *If so, please list any foods to which you have had an al ergic reaction, and the type of reaction: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
PAST SURGERY/OPERATIONS
32. Please list in chronological order (include type, reason, and approximate year): ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
PAST BREAST BIOPSIES
33. How many previous breast biopsies have you had, including any needle core and surgical excisional biopsies?
DO NOT include cyst aspirations or the recent biopsy leading up to your current breast cancer diagnosis.


Which Breast
Needle Core Biopsy or
Diagnosis (please circle the result of your biopsy)
(Right or Left)?
Excisional Biopsy?
Benign Fibroadenoma Atypia (ADH/ALH) LCIS Benign Fibroadenoma Atypia (ADH/ALH) LCIS Benign Fibroadenoma Atypia (ADH/ALH) LCIS PAST CANCER HISTORY
34. Please list al cancers with which you have been diagnosed, the year you were diagnosed, and the treatment(s) received: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
FAMILY HISTORY
Please include only blood relatives, both living and deceased. 39. Do you have any blood related family relatives who have been diagnosed with cancer? If yes, please use the chart below to indicate their relationship to you, the type of cancer they have, their age at diagnosis, and their current age if alive or their age at death. Please provide your best estimate for ages. Maternal
Current Age
Age at Death
Blood Relative
Cancer type
or Paternal
Diagnosis
if Passed
*SAMPLE*: Mother
PATIENT BACKGROUND INFORMATION
40. What is your current employment status? Check one.
r employed less than 32 hours per week r other (please specify ________________________) r part-time student, and also employed less than 32 hours per week 41. Select what best describes your racial background. Check one.
DEFINITIONS FROM FEDERAL GOVERNMENT’S OFFICE OF MANAGEMENT AND BUDGET Have origins in any of the original peoples of North and South America (including Central America) and maintain tribal affiliation or community attachment Have origins in any of the original peoples of the far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam Have origins in any of the original peoples of Africa; includes Haitian r Native Hawai an or Other Pacific Islander Have origins in any of the original peoples of Hawai , Guam, Samoa, or other Pacific Island Have origins in any of the original peoples of Europe, the Middle East or North Africa 42. Were any of your grandparents of Ashkenazi Jewish descent (from France, Germany, Eastern Europe, or Russia)?

Source: http://www.elmhurstoncology.org/downloads/pdf/GresikNewPatient.pdf