Kadlec Imaging Oncology History Form
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PATIENT IDENTIFICATION Healthplex at 1268 Lee Blvd Richland, WA 99352 Phone: 942-2660 GESTATIONAL ASSESSMENT
______Last Name First Name M.I. Date of Birth Height: ______Current Weight: ______Pre-Pregnancy weight: ______*Race: Caucasian African American Hispanic Native American Asian Other : ______* Information requested by the American Diabetes Association for statistical purposes Language: English Other: ______Interpreter Needed? Yes No Highest Level of Education: ______Occupation: Title ______Employer ______Working hours ______Do you live alone? Yes No Primary support person ______Do you have any concerns for your safety in the home? Yes No If yes, explain ______Does anyone in your family have diabetes? Yes No Who? ______Have you had diabetes education in the past? Yes No When? ______Where? ______Educator? ______Do you have difficulty obtaining supplies or medications? Yes No If yes, is the difficulty related to: Cost Transportation Other: ______HEALTH HISTORY Primary Physician: ______Other physicians/problems treated: ______Known Adverse & Allergic Reactions (identify type of reaction)
Known Significant Medical Diagnoses/Conditions Onset Onset Onset Onset Dx/Conditions Dx/Conditions Dx/Conditions Dx/Conditions Date Date Date Date Heart Disease Respiratory Cancer Back/neck pain Chest Pain Sleep Apnea Cataracts Infectious Disease Heart Attack Thyroid Glaucoma Implants/prosthesis Pacemaker Stroke GI/Liver Psych Hx/Depression Hypertension Seizures Kidney Metal in Body Rheumatic Neuro Other: Fever Pregnancy Due Date: No. Pregnancies: Medicine/Prenatal vitamins:
0 7 6 6 1 of 4 Date: 05/22/14 No. Children/Ages:
MEDICATIONS: (Prescriptions, including insulin, oral diabetes medications, inhalers and eye drops, over the counter drugs PATIENT IDENTIFICATION like aspirin and ibuprofen products) Taking No Medications Unable to obtain medication history. Reason ______
Name of Prescribed Medication Dose Frequency Last Dose/Comments
Over the Counter Medications Dose Frequency Last Dose/Comments
Vitamins, Minerals & Herbals Dose Frequency Last Dose/Comments
Known Significant Operative & Invasive Procedures/or Treatment History: Date Date
Date Date
Date Date
------Staff Use Only – Reviewed By: Print Name & Title ______Date of Entry ______Print Name & Title ______Date of Entry ______PERSONAL HISTORY Are you currently experiencing any of the following? No Yes (if answer is yes, continue below) Constipation Changes in appetite Feeling of tiredness Personality changes
#0766 2 of 4 Date: 05/22/14 Have you smoked or used tobacco in the last 12 months? Yes No If yes, how much per PATIENT IDENTIFICATION day? ______What kind? Cigarettes Cigars Chewing tobacco Other: ______Would you like information on quitting or help maintaining your smoke-free status? Yes No Do you drink alcohol? Yes No If yes, how much per day? ______Per week? ______Do you have frequent bladder infections? Yes No
DIABETES MEDICINES (if you are taking any) How many times a week do you: Skip a dose or Take it more than an hour later than planned? ______If you take insulin, where do you inject? Abdomen Arms Leg Other: ______Where do you keep the insulin you’re using now? ______Extra supply of insulin?______
MONITORING Do you check your blood sugar at home? Yes No I don’t have a meter How often do you check your blood sugar? Times per day ______Times per week ______What meter do you use? ______Do you check your urine for ketones? Yes No I don’t know what ketones are Do you ever have low blood sugar reactions? Yes No I don’t know When? ______How many times per week? ______Per month? ______What do you eat or drink for low blood sugar?______Do you carry this with you? Yes No
NUTRITION MANAGEMENT Do you follow any particular nutrition or meal plan? Yes No If yes, what is it? ______Do you follow any of these food restrictions? Low sodium Other: ______ Low fat Low protein How many meals do you usually eat per day? ______Do you eat planned snacks? Yes No How many times a week do you: Skip or Delay a meal or snack? Meals ______Snacks ______How many times a week do you eat away from home? ______Where?______Do you ever binge (eat uncontrollably)? Yes No If yes, how often? ______Who usually shops for food? ______Who usually prepares your food? ______Do you require financial assistance in purchasing food? ______
FOOD RECALL (Describe your typical eating habits) List all foods eaten a typical day and the approximate time you have each meal or snack. Include the specific amount and how it is prepared (fried, broiled, baked, etc.): #0766 3 of 4 Date: 05/22/14 Breakfast Tim Lunch Time: Dinner Time: e:
PATIENT IDENTIFICATION
Mid- Tim Mid- Time: Bedtim Time: morning e: afternoo e Snack Snack n Snack
EXERCISE Has your physician told you to avoid exercise while pregnant? Yes No How often do you exercise per week? ______What kind of exercise do you do? ______How long do you exercise each time? ______What time of day do you exercise? ______PAIN ASSESSMENT Do you have pain? Yes No Is the pain controlled? Yes No Rate pain level on a scale of 1 to 10 (with 10 as the worst): ______Location of pain ______When did it start? ______What causes pain? ______What relieves pain? ______EMOTIONAL ASPECTS OF DIABETES Diabetes affects the whole person and can give rise to feelings of anger, sadness or being overwhelmed. Have you been feeling sad or depressed? Yes No Are you getting less pleasure from your job, sports, or hobbies? Yes No Do you have trouble sleeping? Yes No Do you sleep too much? Yes No Do you often feel down on yourself, that everything is your fault? Yes No Do you have trouble making decisions or concentrating on your work? Yes No Circle any words that describe how you currently feel about your gestational diabetes: Overwhelmed Out of control Hassled Burdened Alone Angry What is you greatest fear about having gestational diabetes? ______Please list the three things that you most want to learn and/or change about your gestational diabetes and how you take care of it: 1. ______2. ______3. ______Patient’s Signature Date Educator’s Signature Date
#0766 4 of 4 Date: 05/22/14