MEDICAL HISTORY QUESTIONNAIRE Welcome! Please complete the following health history before you see your physician. For your convenience this form is also available online at kucancercenter.org. Please print a copy for your records, and bring to your first appointment.
Name: ______Birthdate: ______Date: ______
REASON FOR VISIT: (current symptoms) ______
HERBAL MEDICATIONS OR SUPPLEMENTS: Please include all drugs and supplements you are taking.
Name Dose & Frequency Name Dose & Frequency
1) ______5) ______
2) ______6) ______
3) ______7) ______
4) ______8) ______
MEDICATIONS: Include prescription and over-the-counter medications; feel free to attached a printed or typed list of medications instead.
Name Dose & Frequency Name Dose & Frequency
1) ______7) ______
2) ______8) ______
3) ______9) ______
4) ______10) ______
5) ______11) ______
6) ______12) ______
PREFERRED PHARMACY: Name Address Telephone ______HISTORY: Do you have Living Will or Advanced Directive? o Yes o No
CANCER MEDICAL HISTORY: o Anal Cancer o Kidney Cancer o Rectal Cancer o Bladder Cancer o Larynx Cancer o Renal Failure o Brain Cancer o Leukemia o Sarcoma o Breast Cancer o Mesothelioma o Skin Cancer o Cervical Cancer o Multiple Myeloma o Small cell lung cancer o Cirrhosis o Myelodysplastic Syndrome o Stomach Cancer o Colon Cancer o Neuroendocrine Cancer o Testicular Cancer o Coronary Artery Disease o Non-Hodgkins Lymphoma o Thyroid Cancer o Esophageal Cancer o Non-Small Cell Lung Cancer o Tongue Cancer o Gastric Cancer o Ovarian Cancer o Unknown Primary Cancer o Hepatobiliary Cancer o Pancreatic Cancer o Uterine Cancer o Hodgkin’s Lymphoma o Prostate Cancer
MEDICAL HISTORY: o Acute infection o Gout o Sexual disease o Arthritis o Hearing problems o Stomach problem o Back pain o Heart disease o Stroke o Birth defect o High blood pressure o Thyroid disease o Bleeding tendency o Home oxygen use o Ulcer o Cancer o Osteoporosis o Vision problems o Diabetes o Seizure disorder
OTHER MEDICAL HISTORY: ______
WOMEN ONLY - OB/Gyn History: LMP: ______Having Periods?: o Yes o No Age of first menstrual cycle: ______Age of first live birth: ______Number of live births: ______Number of pregnancies: ______Did you Breastfeed?: o Yes o No If yes, for how long?: ______CANCER SURGICAL HISTORY: Surgery Type o Adrenalectomy (adrenal) o Nephrectomy (kidney) o Cytoreductive Surgery (chemo during surgery) o Parathyroid o Right Colectomy (colon) o Port Placement o Left Colectomy (colon) o Prostatectomy (prostate) o Esophagectomy (esophagus) o Sigmoidectomy (partial colon) o Hepatico-Jejunostomy (liver/intestine) o Thyroidectomy (thyroid) o Lymph Node Biopsy o Whipple (pancreas) o Lymphadectomy (lymph nodes)
SURGICAL/PROCEDURAL HISTORY: Surgery Type o Appendectomy (appendix) o Colonoscopy o Cardiac Catheterization (heart cath) o Cholecystectomy (gall bladder) o Hysterectomy (uterus)
OTHER SURGICAL HISTORY: ______
ALLERGIES: Please list any allergies to medications or foods. Examples of reactions: rash or hives, trouble breathing, nausea. Name Reaction 1) ______2) ______3) ______4) ______5) ______6) ______
MAINTENANCE: DATE OF LAST TETANUS SHOT ______LAST FLU SHOT:______LAST PNEUMONIA SHOT: ______SUBSTANCE HISTORY: Tobacco Use: o Current Every Day Smoker o Light Tobacco Smoker o Current Some Days Smoker o Never Smoked o Former Smoker – Quit Date: ______o Passive, Smoke Exposure – Never Smoked o Heavy Tobacco Smoker o Smoker, Current Status Unknown Tobacco Type: o Cigarettes o Pipe o Cigars
Packs/Day: o .25 o .5 o 1 o 1.5 o 2 o 3
Years: o .5 o 1 o 2 o 3 o 4 o 5 o 10 o 15 o ____ years
Smokeless Tobacco: o Current User Types: o Snuff o Chew o Former User Quit Date: ______o Never Used o Unknown
Ready To Quit: o Yes o No
Alcohol Use: o Yes o No
Drinks/Week: ______Glasses of Wine ______Cans of Beer ______Shots of liquor ______Drinks containing 0.5 oz of alcohol
Drug Use: o Yes o No Per Week:______Type: o Marijuana o Methamphetamines o Cocaine o IV o Heroin o PCP o Other: ______
PAST HOSPITALIZATIONS: ______
REFERRING PROVIDER: Primary Care Physician: ______Address: ______Phone Number: ______Referring Provider: ______Address: ______Phone Number: ______FAMILY HISTORY:
Please indicate the age of diagnosis (if known) AND if the family member is A = Alive D = Deceased Mother Father Sister Brother Maternal Aunt Maternal Uncle Paternal Aunt Paternal Uncle Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Other
Cancer – Breast
Cancer – Colon
Cancer – Lung
Cancer – Ovarian
Cancer – Prostate
Cancer – Thyroid
Cancer – Uterine
Cancer
Diabetes
Heart Disease
Hypertension
Asthma
High Cholesterol
Arthritis – Rheumatoid
Arthritis – Osteoporosis
Stroke
Thyroid Disease
Seizures
Migraines
Rashes/Skin Problems
Depression
None Reported
Unknown to Patient
Coronary Artery Disease
Hyperlipidemia
FAMILY HISTORY UNKNOWN o Please indicate if you are experiencing any of the symptoms below.
General Eyes GU Neurological o Activity change o Eye discharge o Difficulty urinating o Dizziness o Appetite change o Eye itching o Painful urination - Dysuria o Facial asymmetry o Chills o Eye pain o Incontinence - Enuresis o Headaches o Sweating - Diaphoresis o Eye redness o Flank pain o Light-headedness o Always tired - Fatigue o Light sensitivity - Photophobia o Frequency o Numbness o Fever o Visual disturbance o Genital sore o Seizures o Unexpected weight change Respiratory o Blood in urine - Hematuria o Speech difficulty HENT o Sleep disturbance - Apnea o Urgency o Fainting - Syncope o Congestion o Chest tightness o Urine decreased o Tremors o Dental problem o Choking GU (male only) o Weakness o Drooling o Cough o Penile discharge Hematologic o Ear discharge o Shortness of breath o Scrotal swelling o Enlarged lymph node - Adenopathy o Ear pain o Inhale wheeze (Stridor) o Testicular pain o Bruises/bleeds easily o Facial swelling o Wheezing GU (female only) Psychiatric o Mouth sores Cardiovascular o Menstrual problem o Agitation o Nosebleeds o Chest pain o Pelvic pain o Behavior problem o Postnasal drip o Leg swelling o Vaginal bleeding o Confusion o Runny nose - Rhinorrhea o Rapid heartbeat - Palpitations o Vaginal discharge o Decreased concentration o Sinus Pressure GI (Gastrointestinal) o Vaginal pain o Dysphoric mood o Sneezing o Abdominal distention MS (joint/bone) o Hallucinations o Sore throat o Abdominal pain o Joint pain - Arthralgia o Hyperactive o Ringing in ear - Tinnitus o Anal bleeding o Back pain o Nervous/anxious o Trouble swallowing o Blood in stool o Gait problem o Self-injury o Voice change o Constipation o Joint swelling o Sleep disturbance o Diarrhea o Muscle pain (Myalgia) o Suicidal ideas o Nausea o Neck pain Other o Rectal pain o Neck stiffness o Vomiting Skin o Color change o Pale skin - Pallor o Rash o Wound