Affix Patient Label Here
Health Questionnaire/Problem Summary
Breast Center
Reviewed on: (to be completed by staff)
* Allergies to Medications:
* Do you have a Pacemaker?
* Is there a possibility you may be pregnant?
No
No
Yes
Yes, Please list medication(s) and reaction: _____________________
Yes
No
Unknown
Medical History (please list past and current conditions):
Medical Problems
Surgeries
* Medication(s) to be completed on Ambulatory Services Form *
Family History:
If Living:
Age
If Deceased:
Age (at death)
Cause
Have any of your immediate relatives ever had cancer?
If Yes, please list type of cancer?
Father
Mother
Brother/ Sister
Social History:
Marital Status:
Single
Married
Domestic Partner
Separated
Divorced
Widow
How often do you drink alcohol?
Never
Rarely
Moderately
Daily
No
Yes
If yes, how many packs a day?
Do you smoke or chew tobacco?
Have you ever smoked or chewed tobacco?
No
Yes If yes, how many years have you used tobacco?
Are you employed?
No
Yes
If yes, what is your occupation?
Would transportation to UCLA for daily treatments be difficult for you?
No
Yes
If Yes, please specify:
System Review:
Do you have any of the following recently:
General
Fevers
Night Sweats
Chills
Recent weight change
UCLA Form #500546 Rev. (03/09)
Yes No Genitourinary:
Frequent urination
Night time urination
Burning or painful urination
Blood in urine
Kidney stones
Yes
No
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Yes
No
Yes
Skin:
Hives
Eczema
Rash
Musculoskeletal:
Joint Pain
Joint Swelling
Injuries or Joint Fractures
Eyes, Ears, Nose & Throat:
Eye Disease or injury
Do you wear glasses
Change in vision
Change in hearing
Nose Bleeds
Psychiatric:
Depression
Anxiety
Hallucinations
Paranoia
Neurological:
Fainting spells
Convulsions
Headaches
Respiratory:
Shortness of breath
Cough
Wheezing
Hematologic:
Anemia
Have you had difficulty w/excessive bleeding
Have you had abnormal bruising or bleeding
Swollen glands
Cardiovascular:
Chest Pain
Shortness of breath while walking or lying
Down.
Difficulty walking two blocks
Swelling of hands, feet or ankles
Heart Murmur
Endocrine:
Excessive thirst
Intolerance to heat/cold
Gastrointestinal:
Peptic ulcer (stomach or duodenal)
Black stool
Recent change in bowel habits
Frequent diarrhea
Heartburn or indigestion
Immunology/Allergy:
Itchy eyes
Allergies to animal or plants
Runny Nose
Gynecological (female Patients only):
Date of first day of last period
Age periods first started
Number of pregnancies?
Number of children:
Number of miscarriages:
Have you ever taken hormone replacement
medications?
If yes, what type?
Have you ever taken Birth Control Pills?
If yes, how long?
Have you ever breastfed?
Date of last Mammogram:
List any other test:
Age at first live birth?
Date of last PAP smear:
Breast History:
Do you have any lumps in your breasts?
Do you have breast pain?
Do you have discharge?
Please list any other symptoms:
UCLA Form #500546 Rev. (03/09)
Right
Right
Right
Left
Left
Left
How Long?
How Long?
How Long?
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No