The Mount Sinai Hospital One Gustave L. Levy Place New York, New York 10029 BREAST SURGICAL ONCOLOGY: NEW VISIT FORMS Elisa R. Port, MD, FACS Hank Schmidt, MD, PhD, FACS Christina Weltz, MD Ph) 212-241-3806 Fax) 212-202-4590 Ph) 212-241-5928 Fax) 212-202-4633 Ph) 212-241-3956 Fax) 212-241-0703 In order to ensure the highest quality of care, in a timely fashion, it is important that we have all of your medical information at the time of your initial visit. For your initial visit, we ask you to bring any documentation pertaining to tests/procedures you have had done. We also ask that you fax all reports and send all radiology images to our office prior to the appointment. Providing all the medical information prior to your visit will make your visit more comprehensive. Listed below are tests/procedures you may have had. RADIOLOGY FILMS AND REPORTS: The physicians will require all films and reports prior to your appointment. Please provide any tests you have had i.e.: mammogram, sonogram, MRI. Please ensure that all films, for both sides of your breast, be sent even if only one side is affected. Your surgeon needs both the films and corresponding reports to provide a complete evaluation to provide an appropriate assessment and plan. Official radiology reports can usually be provided to you by the ordering physician’s office. We will have to reschedule visits when films and reports are not available for the doctor’s review. ADDRESSES: Please bring complete addresses, phone numbers and fax numbers for any of your doctors who you would like reports sent. PATHOLOGY REPORTS: If you have had a biopsy at another institution, please have that report sent our office. PATHOLOGY SLIDES: If there is going to potentially be treatment and your pathology slides are at another institution, they will want them to be reviewed by our pathologists here at Mount Sinai. Please obtain them from the hospital where your biopsy was performed. Call the Pathology Department of that hospital to arrange to personally pick them up or if it is more convenient, you can request that the hospital send your slides to our office. OPERATIVE REPORTS: If you have had breast surgery recently with another surgeon please call that office and request a copy of the operative report to be sent to us. INSURANCE REFERRALS: Please check with your insurance carrier to find out if your plan requires a referral from your primary care physician. This information can be found on your insurance card. If a referral is not present at the time of the appointment, it will be the patient’s responsibility for services rendered and/or you may be rescheduled. Having this information available for review at the time of your visit will allow our physicians to provide you with the highest quality of care. If there are studies or results you cannot provide for the visit, we recommend you reschedule your appointment to a time when you will be able to provide everything. Should you have any further questions regarding what to bring please call our offices at the number listed above. MR-1775 Page 1 of 7 Pages The Mount Sinai Hospital One Gustave L. Levy Place New York, New York 10029 BREAST SURGICAL ONCOLOGY: NEW VISIT FORMS Name:____________________________________________________________________ NOTE TO PERSON DESIGNING FORM Date of Birth:_____________________ Age:____________________ All text, lines, etc. must be within the established margins as noted. Preferred phone number:____________________________________ (The outside line should not be included on the final form) Primary Insurance Plan:______________________________________ With whom is your appointment?: _____________________________________________ FONT: No smaller than 8 points nor larger than 14 points. Appointment Date: _____________________________________ Document is typed in standard Arial. REASON FOR VISIT SIZE: - - Only forms measuring 8.5" x 11.0" are sized for inclusion within the medical chart. Referring Physician: ______________________________________________________ - - For Landscape Design ensure margin with hole punch = .75" Reason for referral: _______________________________________________________ PAPER: White 20# paper. Was your referral due to a finding on a breast exam by a physician? YES NO Which breast?INK:Right Black isLeft required. Both Did you find something self exam? YES NO FORM # &on APPROVED/REVISION DATE: If so, when did you find it? ________________________________________ Must appear on all pages of the form in the lower left hand corner. Do you have symptoms? YES NO Pain YES NO GENERAL: - - Avoid shading. Nipple Discharge YES NO - - Live data should not be used Lump YES NO - - If it is impossible to eliminate live data from an IT generated form, the name and MRN Skin Changes (rash or dimpling) YES NO MUST be blacked out. Other______________________________ GYNECOLOGICAL HISTORY MULTIPLE PAGES: - - Indicate Page __ of ___ Pages on lower right hand corner of all pages. What age did you first start menstruating? __________ - - Patient name and medical record number should be included on each When was your last menstrual subsequent period? _____________ page. Have you ever been pregnant? Are you currently pregnant? Due date: ______________________ # of pregnancies: ____ # of children: _____ Did you breastfeed? If yes, how long?________________ YES YES NO NO Age of first delivery? _______ YES NO YES NO Have you ever taken hormone replacement pills? If yes, When? _____________________ How long? ______________________ Have you ever taken oral contraceptives? YES NO If yes, when? _______________ Have you ever been treated for infertility? YES NO If yes, when? _______________ Page 2 of 7 Pages The Mount Sinai Hospital One Gustave L. Levy Place New York, New York 10029 BREAST SURGICAL ONCOLOGY: NEW VISIT FORMS NOTE TO PERSON DESIGNING FORM All text, lines, etc. must be within the established margins as noted. (The outside line should not be included on the final form) BREAST HISTORY Have you ever had breast surgery in the past? FONT: YES NO If so, when? _______________ No smaller than 8 points nor larger than 14 points. What was the diagnosis?Document ____________________________________ is typed in standard Arial. Type of surgery? _________________________________ SIZE: - - Only forms measuring 8.5" x 11.0" are sized for inclusion within the medical chart. - - For Landscape Design ensure margin with hole punch = .75" Have you ever had a needle biopsy in the past? YES NO If so, when? _______________ PAPER: 20# paper. What was the diagnosis?White _____________________________________ MEDICAL HISTORY INK: Black is required. Height: _________________ Weight: _________________________ FORM # & APPROVED/REVISION DATE: corner. □ High Blood Pressure Must appear on all pages of the form in the lower left hand YES NO □ Diabetes YES NO GENERAL: - - Avoid shading. □ Cardiac Disease YES NO - - Live data should not be used □ Asthma/COPD YES NO □ Blood clot YES form, NO the name and MRN - - If it is impossible to eliminate live data from an IT generated □ Other ___________________________________________________ MUST be blacked out. Do you currently have pain, unrelated to your reason for visit? YES NO MULTIPLE PAGES: If yes, are you seeing an MD/NP/PA for this pain? YES NO - - Indicate Page __ of ___ Pages on lower right hand corner of all pages. If yes, on a scale of 1-10, how would you rate your pain?______________________________ - - Patient name and medical record number should be included on each page. Have you fallen in the last subsequent year? YES NO Do you require walking aids (cane, walker, wheelchair)? YES NO Do you have episodes of dizziness or fainting? YES NO PAST SURGICAL HISTORY: Please list below all your past operations with reason and date. OPERATION REASON DATE ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Page 3 of 7 Pages The Mount Sinai Hospital One Gustave L. Levy Place New York, New York 10029 BREAST SURGICAL ONCOLOGY: NEW VISIT FORMS NOTE TO PERSON DESIGNING FORM All text, lines, etc. must be within the established margins as noted. (The outside line should not be included on the final form) MEDICATIONS/ALLERGIES: Left Margin Right Margin .75" .4" Do you take Coumadin (Warfarin), Plavix, Aspirin, Vitamin E or any other blood thinning medications? YES NO FONT: No smaller than 8 points nor larger than 14 points. Are you allergic to any medications? Document is typed in standard Arial. If so, please list medication and reaction: YES NO SIZE: - - Only forms measuring 8.5" x 11.0" are sized for inclusion within the medical chart. _____________________________________________________ - - For Landscape Design ensure margin with hole punch = .75" _____________________________________________________ PAPER: White 20# paper. _____________________________________________________ INK: SOCIAL HISTORY Black is required. FORM # & APPROVED/REVISION DATE: Occupation: ______________________________________ Must appear on all pages of the form in the lower left hand corner. Do you currently smoke? YES NO If Yes, # of packs/year________________ GENERAL: - - Avoid shading. Have you smoked in the past? YES NO When did you quit? ___________________ - - Live data should not be used eliminate live data an IT generated form, the name and MRN Do you consume alcohol? - - If it is impossible to YES NO Howfrom often?__________________________ MUST be blacked out. Do you take any recreational drugs? YES NO How often?________What kind?_________ MULTIPLE PAGES: FAMILY HISTORY OF CANCER - - Indicate Page __ of ___ Pages on lower right hand corner of all pages. - - Patient name and medical record number should be included on each □ None subsequent page. □ Breast Cancer Relationship _______________________ Age at diagnosis _______ Relationship _______________________ Age at diagnosis _______ □ Ovarian Cancer Relationship _______________________ Age at diagnosis________ Relationship _______________________ Age at diagnosis________ □ Other ________________ Relationship _______________________ Age at diagnosis ________ Relationship _______________________ Age at diagnosis_________ Have you or anyone in your family been tested for BRCA 1 & 2 breast cancer gene? YES NO If so who: _____________________________________________________________________ _______________________________________________________________________________________ Page 4 of 7 Pages The Mount Sinai Hospital One Gustave L. Levy Place New York, New York 10029 BREAST SURGICAL ONCOLOGY: NEW VISIT FORMS NOTE TO PERSON DESIGNING FORM All text, lines, etc. must be within the established margins as noted. (The outside line should not be included on the final form) REVIEW OF SYSTEMS: Please check “Yes” or “No” as they relate to your health. FONT: No smaller than 8 points nor larger than 14 points. Constitutional Gastrointestinal Document □ Fatigue YESis typed NO in standard Arial. □ Change in Stool YES NO □ Fever YES NO □ Abdominal pain YES NO □ Chills NO Constipation YES chart. NO SIZE: - - OnlyYES forms measuring 8.5" x 11.0"□are sized for inclusion within the medical □ Weight loss NODesign ensure margin □ Other _____________ - - For YES Landscape with hole punch = .75" □ Other _____________ PAPER: White 20# paper. Cardiac □ Chest pain YES NO Black is required. □ PalpitationsINK: YES NO □ Dizziness YES NO FORM # & APPROVED/REVISION DATE: □ Other _____________ Genitourinary □ Painful urination □ Bloody urination □ Other _____________ YES YES NO NO Must appear on all pages of the form in the lower left hand corner. Respiratory Eyes, Ears, Nose and Throat □ Shortness GENERAL: of Breath - - Avoid YES NO □ Change in Vision YES NO shading. □ Coughing YES NO □ Pain Swallowing YES NO - - Live data should not be used □ Wheezing YES NO □ Vertigo YES NO - - If it is impossible to eliminate live data from an IT generated form, the name and MRN □ Other _____________ □ Nasal Stuffiness YES NO MUST be blacked out. □ Other _____________ Neurologic MULTIPLE PAGES: Musculoskeletal □ Headaches YESPage NO Jointright pain YES - - Indicate __ of ___ Pages on□lower hand corner of all pages. □ Dizziness YES NO □ Muscle spasm YES - - Patient name and medical record number should be included on each □ Numbness YES NO □ Swelling YES subsequent page. □ Memory Loss YES NO □ Other _____________ □ Other _____________ Vascular □ Leg cramps □ Tissue loss □ DVT □ Other _____________ YES YES YES NO NO NO Psychiatric □ Anxiety □ Change in sleep pattern □ Depression □ Other ____________ YES YES YES NO NO NO NO NO NO Page 5 of 7 Pages The Mount Sinai Hospital One Gustave L. Levy Place New York, New York 10029 BREAST SURGICAL ONCOLOGY: NEW VISIT FORMS PHYSICIANS: Please list the physicians would like reports All text, lines, etc. must beyou within the established margins as noted.sent to below. NOTE TO PERSON DESIGNING FORM (The outside line should not be included on the final form) Name: _______________________________________________ Address: _____________________________________________ _____________________________________________________ FONT: No smaller than 8 points nor larger than 14 points. City, State, Zip Code: _______________________________ Document is typed in standard Arial. Phone: ____________________________ SIZE: - - Only forms measuring 8.5" x 11.0" are sized for inclusion within the medical chart. Fax: _______________________________ - - For Landscape Design ensure margin with hole punch = .75" PAPER: White 20# paper. Name: ________________________________________________ Black is required. Address:INK: ______________________________________________ ______________________________________________________ FORM # & APPROVED/REVISION DATE: City, State, Zip Code: _______________________________ Must appear on all pages of the form in the lower left hand corner. Phone: ____________________________ GENERAL: - - Avoid shading. Fax: _______________________________ - - Live data should not be used - - If it is impossible to eliminate live data from an IT generated form, the name and MRN PREFERRED PHARMACY: Please list your preferred pharmacy contact information below. MUST be blacked out. MULTIPLE PAGES: - - Indicate Page __ of ___ Pages on lower right hand corner of all pages. Name: ________________________________________________ - - Patient name and medical record number should be included on each Address: ______________________________________________ subsequent page. ______________________________________________________ City, State, Zip Code: _______________________________ Phone: ____________________________ Fax: _______________________________ PATIENT NAME (Print)_____________________________________ PATIENT SIGNATURE______________________________________DATE____________ Page 6 of 7 Pages The Mount Sinai Hospital One Gustave L. Levy Place New York, New York 10029 BREAST SURGICAL ONCOLOGY: NEW VISIT FORMS NOTE TO PERSON DESIGNING FORM All text, lines, etc. must be within the established margins as noted. (The outside line should not be included on the final form) HOME MEDICATION LIST: Please list all prescription, over the counter and herbs/supplements. NAME Example: Aspirin FONT: 1. 2. ROUTE Oral DOSE 81 mg FREQUENCY Daily ___________ No smaller than 8 points nor larger than 14 points. Document is typed in standard Arial. SIZE: - - Only forms measuring 8.5" x 11.0" are sized for inclusion within the medical chart. - - For Landscape Design ensure margin with hole punch = .75" 3. 4. 5. 6. PAPER: White 20# paper. INK: Black is required. FORM # & APPROVED/REVISION DATE: Must appear on all pages of the form in the lower left hand corner. GENERAL: - - Avoid shading. - - Live data should not be used 7. - - If it is impossible to eliminate live data from an IT generated form, the name and MRN MUST be blacked out. 8. MULTIPLE PAGES: 9. 10. - - Indicate Page __ of ___ Pages on lower right hand corner of all pages. - - Patient name and medical record number should be included on each subsequent page. MEDICATIONS/ALLERGIES: Are you allergic to any medications? YES NO If so, please list medication and reaction below: _____________________________________________________ _____________________________________________________ PATIENT NAME (Print)_____________________________________ PATIENT SIGNATURE______________________________________DATE____________ CLINICIAN NAME (Print)____________________________________ CLINICIAN SIGNATURE__________________________REVIEWED DATE____________ Page 7 of 7 Pages