MRN:
Patient Name:
PATIENT HEALTH QUESTIONNAIRE
Radiation Oncology
(Patient Label)
REVIEWED DATE / INITIALS
SAFETY:
Are you at risk for falls?
Do you have a Pacemaker?
Females; Is there a possibility you may be pregnant?
YES
NO
ALLERGIES:
YES
Do you have
medications?
any
allergies
to
NO
If YES, please list medication allergies:
Are you allergic to iodine/IV contrast
dye?
___________________________________________________________________________________
PERTINENT HISTORY
Medical History (please list past and current conditions):
Medical Problems
Surgeries
Do you have any of the specific medical conditions listed below:
YES
NO
Inflammatory Bowel Disease
Crohn’s Disease
Ulcerative Colitis
Lupus
Scleroderma
Claustrophobia
UCLA Form #500704 Rev. (01/12)
Page 1 of 5
MRN:
Patient Name:
PATIENT HEALTH QUESTIONNAIRE
Radiation Oncology
(Patient Label)
Have you ever had:
YES
NO
Previous Radiotherapy
Previous Chemotherapy
GYNECOLOGICAL (female patients only):
Number of pregnancies:
Number of children:
Age at first live birth:
Age periods first started:
Age at menopause (if
postmenopausal):
Menopause Status:
Have you ever taken oral contraceptives or
hormone replacement medication?
If yes, what type:
YES
NO
Date of last Pap Smear:
Date of last Mammogram:
Premenopausal
Postmenopausal
Don’t know
FAMILY HISTORY
YES
Have any of your family members ever had
cancer?
If yes, please list relationship and type of cancer in your family member(s):
NO
SOCIAL HISTORY:
Smoking
YES
NO
If you smoke currently or have smoked in the
past:
Number years smoked
Number packs per day
Number years quit
YES
NO
If you drink alcohol currently or have done
so in the past:
Number days
drink/week
Number drinks/day
Never smoked
Smoke currently
Smoked previously
Alcohol
Never drink alcohol
Occasionally drink
alcohol
Frequently drink alcohol
UCLA Form #500704 Rev. (01/12)
Number years quit
Page 2 of 5
MRN:
Patient Name:
PATIENT HEALTH QUESTIONNAIRE
Radiation Oncology
(Patient Label)
Employement:
Are you employed?
NO
If yes, what is your occupation:
YES
YES
Support Systems:
Do you live alone?
Do you live with your spouse, significant other, family or friends?
Do you live in your own house/appartment?
Do you live in a nursing home?
Do you live in an assisted living environment?
Other comments:
Transportation:
Would transportation to UCLA for daily treatments be difficult for you?
If Yes, please explain:
YES
NO
NO
System Review: Please check “yes” or “no” box to indicate if you have any of the following
YES
Immunology/Allergy
Allergies to animals or plants
Reactions (Runny Nose or itchy
eyes)
Cardiovascular
Irregular heart beat (arrythmias)
Chest Pain
Difficulty walking two blocks
(dyspnea)
Swelling of hands, feet or ankles
(edema)
Shortness of breath while walking
or lying down (orthopnea)
Heart Murmur (palpitations)
UCLA Form #500704 Rev. (01/12)
NO
YES
NO
Genitourinary (Female)
Burning or painful urination
Frequent urination
Blood in urine
Incontinence
Frequent night time urination
Kidney / bladder stones
Sexual difficulty
Urgency with urination
Urine color change
Vaginal discharge/bleeding
Vaginal spotting
Page 3 of 5
MRN:
Patient Name:
PATIENT HEALTH QUESTIONNAIRE
Radiation Oncology
(Patient Label)
System Review (Continued): Please check “yes” or “no” box to indicate if you have any of the following
YES
Constitutional
Poor appetite
Fatigue
Fevers
Lethargy (sluggisness, sleepiness)
Malaise (uneasiness)
Night Sweats
Chills
Recent Weight Change: Gain
Loss
If yes, amount: _________lbs
Endocrine
Hot flashes
Menstrual irregularities
Intolerance to hot/cold (thyroid
disease)
Ears, Nose & Throat
Pain swallowing / Sore throat
(dysphagia)
Ear pain
Nose bleeding (epistaxis)
Change in hearing ability
Mouth dryness
Oral bleeding
Ear infection (otitis)
Sinus infection (sinusitis)
Excessive sputum production
Taste changes
Ear ringing
Voice change
Eyes
Blurred vision
Double vision
Excessive tearing (lacrimation)
Night blindness
Excessive light sensitivity
(photophobia)
Other visual difficulties / changes
in vision
UCLA Form #500704 Rev. (01/12)
NO
YES
NO
Genitourinary (Male)
Burning or painful urination
Frequent urination
Blood in urine
Impotence
Incontinence
Frequent night time urination
Kidney / bladder stones
Scrotal/testicular swelling
Urgency with urination
Urine color change
Hematologic
Abnormal bruising or bleeding
Swollen glands (lymph nodes)
Skin
Blisters
Abnormal itching (pruritus)
Rash
Musculoskeletal
Inflammation of joints (arthritis)
Bone Pain
Joint Pain
Muscle weakness
Range of motion problems
Psychiatric
Depression
Anxiety
Respiratory
Cough
Blood in sputum (hemoptysis)
Page 4 of 5
MRN:
Patient Name:
PATIENT HEALTH QUESTIONNAIRE
Radiation Oncology
(Patient Label)
System Review (Continued): Please check “yes” or “no” box to indicate if you have any of the following
YES
Gastrointestinal
Abdominal pain
Recent change in bowel habits
Constipation
Frequent diarrhea
Heartburn or indigestion
Fresh blood in stools
Hemorrhoids
Black stools
Nausea
Vomiting
NO
YES
NO
Neurological
Disorientation
Dizziness
Gait problems
Headaches
Insomnia
Memory loss
Motor weakness
Paralysis
Convulsions (seizures)
Sensory problems
Stroke
Patient Signature: ____________________________________ Date: _____________ Time: ________
If completed by an individual other than the patient, please state relationship to the patient: __________
___________________________________________________________________________________
This Past Medical History, Family History, Social History, and Review of Symptoms have been reviewed
with the patient, by the physician(s) noted below:
Resident Signature: __________________________________ Date: _____________ Time: ________
Attending Signature: __________________________________ Date: _____________ Time: ________
UCLA Form #500704 Rev. (01/12)
Page 5 of 5