HEMATOLOGY/ONCOLOGY New Patient Questionnaire

DEPARTMENT OF HEMATOLOGY/ONCOLOGY

PLACE LABEL HERE

HEMATOLOGY/ONCOLOGY New Patient Questionnaire: Sex: ______Person completing this form: ______Why are you here to see the doctor? ______Does the child have any allergies (including environmental, medication, food, reaction to previous blood transfusion)? YES NO If YES - Please list: ______Is the child currently taking any medications or drugs (including over-the-counter, prescription, health store medications, birth control pills)? YES NO If YES - Please list: ______Does the child have any chronic conditions or any previous serious illnesses? YES NO If YES - Please list: ______

SURGICAL/HOSPITALIZATION HISTORY: NO YES Date Surgery Performed and/or General Anesthesia or List any problems with Reason for Hospitalization Sedation Given? General Anesthesia YES NO YES NO YES NO

PATIENT SUBSTANCE USE: Tobacco: Never Quit Passive YES / Alcohol: NO YES ______oz/wk / Drugs: NO YES ______use/wk

BIRTH HISTORY:

Full Term Premature (Weeks ____) Vaginal Caesarean Healthy at Birth Birth Length: ______Birth Weight: ______If Hospitalized, Where? ______Birth/Pregnancy Problems (if any): ______

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Please return completed form to the medical assistant or nurse.

FAMILY HISTORY: Please indicate the child’s family history. For Aunt, Uncle and Grandparents note M for Maternal and P for Paternal

None Mother Father Brother Sister Aunt Uncle Grandmother Grandfather DVT/pulmonary embolism Kidney Disease Heart Disease Asthma Stroke Congenital Hearing Loss Anemia Bleeding Problems Sickle Cell Anemia Diabetes Cancer Anesthesia Problems Hypertension OTHER

SOCIAL HISTORY: Are there any smokers in the patient’s home? YES NO If YES - Who? ______Child lives with (check applicable) Mom Dad Grandparent Brother (#): ___ Sister (#): ___ Foster Parent Legal Guardianship/Custody: ______Mother’s Age: ______Mother’s level of education: High school diploma/GED Some College College Graduate Father’s Age: ______Father’s level of education: High school diploma/GED Some College College Graduate List all sibling(s) Name: ______Age: _____ Same Parents YES NO / Name: ______Age: _____ Same Parents YES NO Name: ______Age: _____ Same Parents YES NO Name: ______Age: _____ Same Parents YES NO Name: ______Age: _____ Same Parents YES NO Name: ______Age: _____ Same Parents YES NO Pets: ______Other: ______Is the patient enrolled in CMS? YES NO Other Agencies involved with this patient? YES NO Agency Name: ______Do you have transportation needs? YES NO If YES - Please explain: ______

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Please return completed form to the medical assistant or nurse.

REVIEW OF SYSTEMS: Please indicate wether the following are problems for your child. (CHECK ALL THAT MAY APPLY)

NEWBORN: RESPIRATORY: HEPATIC: Healthy at Birth Normal Normal Apnea Asthma Liver Disease Retinopathy Shortness of Breath Jaundice (Yellow Skin) Bradycardia Chest Pain Gall Stones Intraventricular Hemorrhage/Head Bleed TB Hepatitis Incubation/Mechanical Ventilation Aspiration Pancreatitis BPD (Bromchopulmonary Dysplasia) Croup Other/Details: Other/Details: Pneumonia ______Chronic Cough Tracheostomy/Intubation/Mechanical NEUROLOGIC: CONSTITUTIONAL/GENERAL: Other/Details: Normal Normal ______Seizures Frequent Infection Migraines Fever CARDIAC: Stroke Weight Loss Normal Change in School Performance Fatigue Congenital Heart Defects Weakness Unusual Sweating Racing Heart Dizziness Other/Details: Cardiotoxic Drugs Headache ______Blood Pressure Problems Walking Problems Murmurs Hydrocephalus/Shunt EYES: Arrhythmias (Irregular Heartbeat) Meningitis Normal Other/Details: Balance Problems Double Vision ______Other/Details: Glasses ______Blurry Vision GENITOURINARY: Swelling of Eyes Normal GASTROINTESTINAL: Other/Details: Kidney Disease Normal ______UTI (Urinary Tract Infection) Diarrhea Vesicoureteral Reflux Vomiting/Nausea EARS/NOSE/THROAT: Vaginal Bleeding Abdominal Pain/Swelling Normal Excessive Urination Constipation Hearing Problems Stones GE Reflux Chronic Ear Infections Ovary Problems Blood in Stool Bleeding Gums Undescended Testicle Hepatitis Difficulty Swallowing Excessive Menstruation Colitis Nosebleeds Incontinence Vomiting Blood Snoring Pelvic Pain Other/Details: Mouth Sores Blood in Urine ______Loose Teeth Testicular Mass/Pain Frequent Upper Respiratory Infection/Cold Other/Details: Other/Details: ______(Review of Systems continued on next page)

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Please return completed form to the medical assistant or nurse.

REVIEW OF SYSTEMS: Please indicate wether the following are problems for your child. (CHECK ALL THAT MAY APPLY)

MUSCULOSKELETAL: SKIN: ENDOCRINE/METABOLIC: Normal Normal Normal Muscle Disease Rash Diabetes Arthritis Eczema Thyroid Disorders Muscular Dystrophy Easy Bruising Inborn Errors of Metabolism Scoliosis Birthmarks Adrenal Disorders Fractures Scars Other/Details: Neck Pain Pallor ______Back Pain Hemangioma Joint Pain Burns PSYCHOSOCIAL: Bone Pain/Mass Other/Details: Normal Other/Details: ______Developmental Delay ______Learning Disability Substance Abuse HEMATOLOGIC: ADD/ADHD Normal Autism Bleeding Disorder Depression Prior Transfusion Other/Details: Pallor ______Anemia Leukemia Blood Clot Easy Bleeding/Bruising Lymphoma Other/Details: ______

DEVELOPMENTAL HISTORY: Answer all questions that apply to your child’s age. Is your child toilet trained? YES NO If YES Do you have concerns regarding toilet training? ______For Infants/Toddlers: Does your child: Roll over? YES NO Sit alone? YES NO Walk? YES NO Talk? YES NO Drink from a cup? YES NO For Preschool Children: Attend daycare? YES NO Has there been concern over development or speech? YES NO For School Age Children: Grade: ______School: ______School Performance: ______Other activities (work, sports, church, etc): ______Has your child’s intelligence or development ever been tested? YES NO If YES, by Whom, Where, & When? ______

Up to date on Immunizations? YES NO Which: ______For girls: Age first menstruated? ______

Please return completed form to the medical assistant or nurse.