CENTRAL ALABAMA RADIATION ONCOLOGY
Patient Health History Questionnaire
Patient Name:
Birth date:
Address:
City/State/Zip:
Social Security Number:
Marital Status:
Today’s Date:_________
Age:
Height:
Race:
Male
# Of Children
Home Phone:
Female
Cell Phone:
Email:
Ethnicity:
□ Hispanic or Latino □ Non-Hispanic or Non-Latino □ Other or Undetermined
Do you have a living will?
If yes, please provide a copy.
Referring Physician :
Preferred Pharmacy:
__________________________________
_________________________ Phone# ________________
Primary Care physician:
Address:
__________________________________
________________________________________________
Surgeon:
__________________________________
Please list additional Physicians assisting with your care:
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
Reason for your visit today:
When were you diagnosed?
Do you have a PORT/VASCULAR DEVICE?
Do you have an Implanted Pacemaker or Defibrillator?
Problem
Yes
No
AIDS/HIV positive
Alzheimer’s/Dementia
Arthritis
Asthma
Back Problems
Osteoporosis
Crohn’s Disease
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
No
No
No
Cardiac Disease or heart
problems
Diabetes
Emphysema or COPD
Lupus or Scleroderma
GERD (reflux,
heartburn)
Hepatitis
High Cholesterol
High Blood Pressure
Hypothyroid (low)or
Hyperthyroid (high)
Kidney Disease
Dialysis
Stroke or TIA’s
Any Details:
If yes, please show the Nurse your card.
Please list other medical problems not listed:
Date of last mammogram (Female):
Date of last Pap smear (Female):
Date of last PSA (Male):
Date of your last Colonoscopy:
SURGERIES (Provide details, including approximate dates)
EXTENDED HOSPITALIZATIONS (stays in the hospital for more than 48 hours-provide details)
ALLERGIES
Medication
Reaction
Have you ever received intravenous contrast?
Yes
No
If you received IV contrast, did you have any problems?
Yes
No
Do you have any seafood allergies?
Yes
No
MEDICATION HISTORY (List all Medications you are currently taking including vitamins and over the counter medications)
Name of Medication
Strength
Frequency
Reason for taking
Have you received radiation in the past?
Have you received or are you currently receiving Chemotherapy treatments?
Have you met with a Chemotherapy doctor yet?
Date of last Chemotherapy?
Yes
Yes
Yes
No
No
No
FAMILY HISTORY
Father
□ Living
Check all that apply:
□Deceased
Father
Age_____
Mother
Mother
□Living
Brother
□Deceased
Sister
Hypertension
Heart Disease
Stroke
Blood Clots
Blood Disorders
Unusual Bleeding
Diabetes
Cancer (describe)
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Other (describe)
□
□
□
□
Age_____
SOCIAL HISTORY
Do you smoke? □Yes □No
How many years: ______
About how many packs a day:________
Have you ever smoked? □Yes □No If yes when did you quit? _____ How many years did you smoke? ____
Do you drink alcoholic beverages? □Yes □No
If yes, what kind, how often and how much:
Any illegal “street” drug use at present or in the past? □Yes □No
Describe:
Level of Education: Highest grade completed _____
Are you employed? □Yes □No
What is your occupation?
How long have you/did you work at your job(s)?
Did you ever have any chemical or other hazardous material exposure at work? □Yes □No
Describe:
REVIEW OF SYSTEMS (circle one) symptoms within last 2 weeks
CONSTITUTIONAL
Good Appetite
Fatigue
Fever
Weakness (sense of not feeling well)
Night Sweats
Rigors/chills
Weight change
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
EYES
Blurred vision
Double vision
Excessive/abnormal tear production
Night Blindness
Sensitivity to light
Visual difficulties
EARS, NOSE, MOUTH, THROAT
Difficulty swallowing
Ear Pain
Nose Bleeds
Impaired hearing
Hoarseness
Mouth dryness
Oral bleeding
Ear infections
Sinusitis
Mouth sores
Taste altered
Ringing in ears
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
YES
YES
YES
YES
NO
NO
NO
NO
NECK
Masses
Muscle Weakness
Pain
Limited range of motion
Swelling
SKIN
Blisters
Dry skin
Increased sensitivity to sun
Hives, welts, itching, rash
FEMALES: BREAST
Breast masses
YES
Nipple discharge
YES
Nipple inversion
YES
Pain
YES
Bra size ______ *If you have been referred for Breast Cancer please indicate current Bra size (for insurance purposes only)
CARDIAC
Irregular heartbeats
YES
Chest pain
YES
Swelling to feet and legs
YES
Shortness of breath with lying down
YES
Heart racing
YES
GASTROINTESTINAL
Constipation
YES
Diarrhea
YES
Heart burn/Indigestion
YES
Bloody vomit
YES
Rectal Bleeding
YES
Hemorrhoids
YES
Black tarry stools
YES
Nausea
YES
Abdominal Pain/cramping
YES
Feeling full after shortly eating
YES
Vomiting
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
GENITOURINARY
Burning in urination
Frequent urination
Genital Masses
Blood in Urine
Impaired sex function
Accidental loss of bladder or bowel control
Wake up at night to urinate
Scrotal swelling (male only)
Vaginal discharge/bleeding (female only)
Urgency
Urine color change
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
NO
NO
NO
NO
YES
YES
YES
YES
NO
NO
NO
NO
YES
NO
MUSCOLOSKELETAL
Arthritis
Bone Pain
Joint Pain
Muscle weakness
Range of motion
Limited range of motion (where?)
NEUROLOGIC
Disorientation/confusion
Dizziness
Difficulty walking
Headaches
Inability to sleep at night
Memory Loss
Nerve Pain
Loss of Muscle function
Seizure
Difficulty performing daily activities
Stroke
MENTAL HEALTH
Anxiety
Hallucinations
Depression
Mood Swings
ENDOCRINE
Diabetes
Hot Flashes
Menstrual Irregularities (female)
Thyroid Disease
HEMATOLOGICAL/LYMPHATIC
Swollen Lymph Nodes
I attest that all of the information in this document is true and correct to the best of my knowledge
and understand my physician will base his opinions and judgments on the same.
_____________________________________________
___________________
Patient Signature
Date