HEMATOLOGY ONCOLOGY ASSOCIATES OF THE QUAD CITIES, P.C.
Name: ___________________________________________________ Date: ______/_____/_________
DOB: _____ /_____/______
Preferred language:
Ethnicity:
Race:
Age _______
English
Sex:
Male
Female
Other________________________
Hispanic or Latino
Not Hispanic or Latino
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Asian
Black or African American
More than one race
Unknown
Primary care physician: ____________________________________
White
Height: ______ft _______in
Other physicians providing care/specialty: __________________________________________________
Occupation/Former occupation: __________________
Full time
Part time
Retired
Employer: _____________________________________
Are you a military veteran?
Current marital status:
Widowed
Single
Do you have any children:
Married
No
Yes
Divorced
#Sons: ________
Disabled
No
Yes
#Daughters: _______
Whom do you give us permission to speak with on your behalf? (Valid until 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
day
week
Would you agree to a blood transfusion if needed?
Advanced directives:
No
None
each
Chewing tobacco
Yes
Amount: # of drinks ________ per
Religious preference
Pipe
packs
month
Yes
year
No
Yes Please indicate- _______________________________
Do not resuscitate
Durable power of attorney
Living will
Health care proxy
* Please provide office a copy for our records
Patient Name___________________________________ EMR # ___________
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HEMATOLOGY ONCOLOGY ASSOCIATES OF THE QUAD CITIES, P.C.
Females:
Age at menopause: ________
Did menopause occur naturally?
Are you currently taking hormone replacement therapy:
Yes
Yes
No
No
Chronic Medical Conditions
AIDS/HIV
Anemia-Type_______________________
Arthritis
Asthma
Blood clots
Bowel problemsType ___________________________
CVA (stroke)
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 _____
Unknown
Deceased
Age at time of
death_______
Deceased
Age at time of
death_______
Heart problemsType________________-___________
Hepatitis
High cholesterol
High blood pressure
Kidney disease
Liver disease
Lung DiseaseType _____________________
Peptic ulcer disease
Seizure disorder
Thyroid disease
Other-
Lumpectomy R/L When? _________
Mastectomy R/L When? _________
Kidney surgery
Prostate surgery
Gall Bladder surgery
Other surgery:
Adopted
Cause of death:
Cause of death:
History of cancer
Age when diagnosed _____
Type:__________________
History of cancer
Age when diagnosed _____
Type:__________________
Patient Name___________________________________ EMR # ___________
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HEMATOLOGY ONCOLOGY ASSOCIATES OF THE QUAD CITIES, P.C.
Other immediate family members with history of cancer:
Relationship to you
Type of cancer
Age at diagnosis/how are they?
Have you ever broken any bones?
No
Yes
If yes, what bone was broken? ____________________________________ When? _______________
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)
See attached list
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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