Barry J Roseman, M.D.
_____________________________________________________________________________
Surgical Oncology of North Georgia, Inc.
1218 West Paces Ferry Rd, Suite 204
939 Bob Arnold Blvd, Suite F
Atlanta, GA 30327
Lithia Springs, GA 30122
404.841.6262 Office 888.343.1740 Fax
Confidential Medical History
Today’s Date: __________________
Name:
_______________________________________
Age: _______
DOB: ______________________
Social Security Number:
_______________________
Physical Address:
________________________________________________________________________
City, State, Zip Code:
________________________________________________________________________
Mailing Address (if different): ________________________________________________________________________
City, State, Zip Code:
________________________________________________________________________
Home Phone:
_____________________
Cell Phone:
_____________________
Marital Status:
Married { }
Spouse’s Name:
_____________________
Employer:
_________________________________________________________________________
Address:
_________________________________________________________________________
Phone:
_______________________
Spouse’s Employer:
_________________________________________________________________________
Address:
_________________________________________________________________________
Phone:
_______________________
Divorced { }
Single { }
Separated { }
Number of Children::
Occupation:
Occupation:
Widowed { }
_________
__________________________
__________________________
Referring Physician:
__________________________________________
Other Physicians you currently see:
__________________________________________
__________________________________________
Emergency Contact:
______________________
Relationship:
___________________________
Please briefly describe your current condition or problem which prompted this visit.
Barry Roseman, M.D. Confidential Medical History
Page 1
List Current Medications: (Include Medications, Vitamins, Herbs, and Supplements)
Name
dose
how often you take
reason for taking
Pharmacy Name & Phone Number:
(**pain medications cannot be called in**)
Drug or Environmental Allergies
Allergy
Reaction:
Date of last physical examination _________________ by Dr. _____________________
Are you now under the care of a physician?
If yes, who and what is the condition being treated?
Doctor__________________________________ Condition _________________________
Have you ever had any serious illness or operation?
If yes, what illness or operation? ___________________________________________
Date ________________ Location __________________ Doctor ___________________
Have you ever been hospitalized?
If yes, why? _________________________________________________________________
Date ________________ Hospital ___________________ Doctor ___________________
Do you have or have you ever had any of the following problems?
Y
N
Y
N
Y
N
Abnormal Bleeding
AIDS/ HIV Positive
Diabetes - Insulin Dependent
Low Blood Pressure
Diabetes - Oral Medication
Lung Disease
Alcohol Abuse
Difficulty Breathing/Shortness of Breath
Mitral valve prolapse
Allergies or Hay Fever
Drug Abuse
Osteoporosis or Osteopenia
Alzheimer’s Disease
Emphysema
Pace Maker
Anemia
Epilepsy/Seizures
Prosthetic Joint Replacement
Angina Pectoris
Fainting spells
Psychiatric Problems/Nervous Disorder
Anorexia or Bulimia
Fever Blisters
Radiation treatment
Other Eating Disorder
Frequent Headaches
Respiratory disease
Arthritis
Glaucoma
Rheumatic fever
Artificial Heart Valve
Head Injuries
Rheumatism
Asthma
Heart Ailments/ Heart Murmur
Sickle Cell Anemia
Bacterial Endocarditis
Heart Surgery
Sinus trouble
Blood Disorders
Hemophilia
Stomach/Gastrointestinal Disorders
Blood Transfusion
Hepatitis, liver disease (A/B/C)
Stroke
Burning Tongue
High blood pressure
Thyroid or Parathyroid disease
Cancer
Hypoglycemia
Tuberculosis
Chemotherapy - I.V. –Aredia
Intestinal Disease
Tumors or growth
Chemotherapy - I.V. –Zometa
Kidney Problems/Disease/Dialisis
Ulcers
Colitis
Latex Allergy
Venereal disease
Congenital Heart Defect
Leukemia
Xerostomia (Dry Mouth)
Cosmetic Surgery
Barry Roseman, M.D. Confidential Medical History
Page 2
Review of Systems (ROS): These are current problems only
Constitutional:
_____ Fatigue
_____ Weight Loss – unintentional
_____ Weight Gain – abnormal
_____ Night Sweats
_____ Loss of Appetite
_____ Fevers
Eyes:
_____ Visual Disturbances
_____ I currently wear glasses / contacts
_____ Cataracts
_____ Red Eye
_____ Eye Injury or pain
Ears, Nose, Throat:
_____ Loss of hearing
_____ Loss of smell
_____ Sore throat
_____ Hoarseness
_____ Ringing in the ears
Respiratory:
_____ Persistent cough
_____ Wheezing
_____ Coughing up blood
_____ Snoring
Cardiovascular:
_____ Chest pain
_____ Shortness of breath
_____ Heart Palpitations
(skipping, missed, irregular beats)
_____ Leg swelling
Neurological:
_____ Numbness / tingling
_____ Focal weakness
_____ Unusual difficulty with concentration / memory
_____ Walking difficulty
_____ Seizures
_____ Tremors
_____ Speech disturbances
_____ Balance problems
_____ Dizziness
_____ Headaches
_____ Excessive daytime sleepiness
Skin/Breasts:
_____ Rashes
_____ Persistent itching
_____ Moles, which are changing
_____ History of significant sun exposure
_____ Breast tenderness
_____ Nipple discharge
_____ Breast lumps / masses
Gastrointestinal:
_____ Abdominal pain
_____ Vomiting
_____ Pain with swallowing
_____ Food sticking
_____ Spitting up blood
_____ Heartburn
_____ Constipation
_____ Diarrhea
_____ Blood in stool
_____ Black stools
Endocrinology:
_____ Cold / Heat intolerance
_____ Frequency of urination, drinking, or eating
Hematology / Lymph nodes:
_____ Bleeding
_____ Easy bruising
_____ Recurring infections
_____ Lymph node swelling
Muscular-skeletal:
_____ Pain
_____ Muscle cramps
_____ Significant loss of strengths
_____ Restricted joint motion
_____ Joint swelling
_____ Joint pain
_____ Joint deformities
_____ Back pain
Female History:
_____ Last mammogram
_____ Last menstrual period
_____ Number of pregnancies
_____ Live births
_____ Miscarriages
_____ Abortions
_____ Vaginal births
_____ C-section births
_____ Hysterectomy
_____ Painful periods
_____ Irregular periods / bleeding
_____ Heavy periods
_____ Birth control usage
_____ Menopause
_____ Difficulty with conception
_____ Vaginal discharge
_____ Abnormal pap results
_____ Recurrent / Persistent
pelvic pain
_____ Painful intercourse
Male History:
_____ Testicular pain
_____ Testicular enlargement
or atrophy
_____ Hernias
_____ Urinary hesitancy
_____ Frequent urinating at night
_____ Weak urinary stream
_____ Dribbling
_____ Incomplete voiding
_____ Penile discharge
Genital Urinary:
_____ Urinary frequency
_____ Urgency
_____ Pain with urination
_____ Loss of control of urine
_____ Blood in urine
Psychiatric:
_____ Sleep disturbances
_____ Eating disturbances
_____ Depression
_____ Anxiety
_____ Suicidal ideations / attempts
_____ Phobias
_____ Panic attacks
Barry Roseman, M.D. Confidential Medical History
Page 3
Social History
Exercise Habits: _____________________________________________
Daily Caffeine intake: (coffee, tea, soda, chocolate, and energy drinks): ___________
Smoking history:
Currently Smoke: Y/ N
How much do you smoke? _____________
If so, for how long? ___________________
Have you ever smoked in the past?
Y/N
If so, how much did you smoke and when did you quit?
_____________________
Chewing Tobacco: Y / N
Alcohol Consumption: Y / N
How many drinks on average per day/week _____
How many drinks per setting _____
1 drink = 12oz beer, 4oz wine, 1.5oz liquor
Illicit/ Illegal drug usage: Y / N
Current Drugs Used:______________________________
Past drugs Used:________________________________
Do you have any tattoos or body piercing? Y / N
Location? ______________________________________
Do you have any Biomedical or tissue implants?
Breast _____
Dental _____
Knee _____
Hip _____
Heart Valve _____
Head or Jaw _____
Other _____
Family History
High Blood Pressure:
Father
Mother
Brother Sister
Other
__________________________
Diabetes:
Father
Mother
Brother Sister
Other
__________________________
Heart Problems:
Father
Mother
Brother Sister
Other
__________________________
Cancer:
Father
Mother
Brother Sister
Other
__________________________
Other:
Father
Mother
Brother Sister
Other
__________________________
Barry Roseman, M.D. Confidential Medical History
Page 4