HEMATOLOGY ONCOLOGY ASSOCIATES OF THE QUAD CITIES, P.C.
Name ___________________________________________________ Date ______/_____/_________
D/O/B ____ /____/______
Age _______
Sex:
Male
Primary care physician: _______________________
Female
Race __________________
Height: ______ft _______in
Other physicians providing care/specialty____________________________________________________
Occupation/Former occupation: __________________
Full time
Employer: _____________________________________.
Current marital status:
Single
Do you have any children:
Married
No
Yes
Part time
Retired
Are you a military veteran?
Divorced
No
Disabled
Yes
Widowed
#Sons: ________
#Daughters: _______
Whom would you like to give us permission to speak with on your behalf ?
This authorization is valid unless revoked in writing by you.
This does not include release of medical records which requires a written release form.
Name: ___________________________ Relationship: ___________________ Phone ________________
Name: ___________________________ Relationship: ___________________ Phone ________________
________________________________________________ ______/______/______
Signature
Date
Tobacco: use:
No
Former
What type of tobacco?
Alcohol use:
No
Yes # of years________ Amount per day ______
Cigarettes
Former
Cigars
Pipe
day
week
Would you agree to a blood transfusion if needed?
Advanced directives:
No
Chewing tobacco
Yes
Amount: # of drinks ________ per
Religious preference
month
Yes
year
No
Yes Please indicate- _______________________________
None
Do not resuscitate
Durable power of attorney
Age at menopause: _______ Did menopause occur naturally?
surgery
Living will
Health care proxy
Females:
If no, was it a result of
packs
Yes
No
chemotherapy?
Are you currently taking hormone replacement therapy:
Yes
No
Patient Name___________________________________ EMR # ___________
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HEMATOLOGY ONCOLOGY ASSOCIATES OF THE QUAD CITIES, P.C.
Chronic Medical Conditions
AIDS/HIV
Heart problemsType________________-___________
Hepatitis
High cholesterol
High blood pressure
Kidney disease
Liver disease
Anemia-Type_______________________
Arthritis
Asthma
Blood clots
Bowel problemsType ___________________________
CVA (stroke)
Lung DiseaseType _____________________
Peptic ulcer disease
Seizure disorder
Thyroid disease
Other-
Depression
Diabetes
Gastric reflux disease
Have you had cancer, chemotherapy, or
radiation?
Details-
Past surgical history
Appendectomy
Bone marrow or stem cell Transplant?
Which? __________ When?_________
Biopsy of _____________ Date_____
Colon surgery
Eye surgery-Type ________________
Hysterectomy-Vaginal/Abdominal
Complete or partial
Family History of cancer
Mother
Alive & Well
Age ______
Father
Alive & Well
Age _____
Lumpectomy R/L When? _________
Mastectomy R/L When? _________
Kidney surgery
Prostate surgery
Gall Bladder surgery
Other surgery:
Unknown
Adopted
Deceased
Cause of death:
Age at time of
death_______
Deceased
Cause of death:
Age at time of
death_______
History of cancer
Age when diagnosed _____
Type:__________________
History of cancer
Age when diagnosed _____
Type:__________________
Other immediate family members with history of cancer:
Relationship to you
Type of cancer
Have you ever broken any bones?
No
Age at diagnosis/how are they?
Yes
If yes, what bone was broken? ____________________________________ When?_______________
Patient Name___________________________________ EMR # ___________
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HEMATOLOGY ONCOLOGY ASSOCIATES OF THE QUAD CITIES, P.C.
MEDICATION INFORMATION
Preferred pharmacy_____________________________ Location____________________
(Address or intersection)
Mail order pharmacy: ___________________________ Phone # __________________
Drug allergies
Yes
No
Name of Medication
Type of reaction
Hives
Itching
Hives
Itching
Hives
Itching
Hives
Itching
Other:
Other:
Other:
Other:
List all medications or herbal supplements you are taking on a regular basis
(At least once a week)
Medication
Dosage
# of times per day taken
Prescribing doctor
Thank you for taking the time to fill this out so we have the information we need.
The Hematology Oncology Associates staff.
Patient Name___________________________________ EMR # ___________
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