New Patient Information Form - Moores Cancer Center

Encinitas Cancer Center
Vista Cancer Center
PATIENT HISTORY
QUESTIONNAIRE
Patient Identification
To assist the doctors in their evaluation and treatment of your medical problems, kindly take the time
to supply the information requested below. Please be concise and as specific as possible.
Patient Name____________________________________ Female Male
Age__________
Any Surgeries:
Type of Surgery Month/Year Type of Surgery Month/Year
1. 4.
2. 5.
3. 6.
Medical Problems: (i.e., ulcers, stroke, high blood pressure, arthritis, thyroid, cholesterol)
Problem Date of Onset Problem Date of Onset
1. 4.
2. 5.
3. 6.
Current Medications: (include over-the-counter medications)
Name of Medication Dose Frequency/Day I take it for I started it on
1.
2.
3.
4.
5.
6.
Drug Allergies: (Name of drug and reaction i.e., rash, shortness of breath, upset stomach)
Name of Drug
1. 4.
2. 5.
3. 6.
Type of reaction
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D3267 (6-13) Page 1 of 5

PATIENT HISTORY
QUESTIONNAIRE
Patient Identification
Do you use tobacco Yes No
Did you use tobacco in the past Yes No
If you have quit, what year _______
Do you drink alcohol Yes No
Did you drink in the past Yes No
Average number of packs per day ______
Number of years used ______
If yes, estimate the amount you drink regularly:
_____ per day _____ per week
If yes, how long ______________
Family History
Father
Mother
Brothers
Family member Deceased or living Age (current or at death)
Current medical problems or
cause of death
Sisters
Number of Sons ________ Illnesses _________________________________________________
Number of Daughters _______ Illnesses _______________________________________________
Family History
City in which you live _____________________________________
Work: Yes No Retired: Yes No Disabled: Yes No
Type of job: ______________________________________________________________________
Married Single Widowed Divorced How long _________________
Significant hobbies you have_________________________________________________________
Toxic chemical exposure____________________________________________________________
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D3267 (6-13) Page 2 of 5

Review of Systems
PATIENT HISTORY
QUESTIONNAIRE
Do you have diabetes Yes No
RECENTLY, have you had:
Weight loss Yes No If yes, how much______
Decrease in energy Yes No
Decrease in appetite Yes No
Night sweats Yes No
Fever Yes No If yes, how high_____
Patient Identification
Please check if you have experienced any of these symptoms within the past several months.
HEAD, EYES, EARS, NOSE, THROAT
Sinus infection/pain
Ear pain
Change in hearing
Eye pain
Change in vision
Nasal discharge
Throat pain
CARDIAC
Chest pain
Shortness of breath
Fatigue
Episodes of shortness of breath
at night
Decrease in ability to exert oneself
RESPIRATORY
Blood in sputum
Cough or change in cough
Shortness of breath when laying down
Mucous production with cough
GASTROINTESTINAL
Difficulty swallowing food
Pain with swallowing food
Indigestion
Nausea
Vomiting
Diarrhea
Abdominal bloating
Black stools
Blood from the rectum
NEUROLOGICAL
Headaches
Troublesome or frequent headaches
Recent change in vision
Recent change in hearing
Change in ability to feel things
Painful sensations
Decrease in muscle strength
Decrease in ability to walk or more
PSYCHIATRIC
Change in mood
Change in behavior with family
Change in ability to think
Losing track of where one is, what
time it is, or who one is
HEMATOLOGIC
Nosebleeds, rectal bleeding, or
bleeding at other sites Please specify
_______________________________
EXTREMITIES
Redness of a limb
Swelling of a limb
Discoloration of a limb
GENITOURINARY
Burning with urination
Blood in urine
Increased need to urinate
Increase in need to urinate at night
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D3267 (6-13) Page 3 of 5

PATIENT HISTORY
QUESTIONNAIRE
MUSCULOSKELETAL
Arthritis
Back pain
New back pain
Bone pain
Muscle soreness
Recent trauma or fractures
SKIN
Infections
Ulcers
Rashes
Patient Identification
TODAY'S MAIN COMPLAINT
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
Women only
Age at first menstrual period _____ Age at first pregnancy ______
# of pregnancies _______ # of live births ______ # of abortions/miscarriages _____
Did you breast feed Yes No Any previous breast problems Yes No
Previous hysterectomy Yes No Ovaries removed Yes No
Any nipple discharge Yes No Do you do breast self exams Yes No
Do you feel any mass now Yes No Any nipple or breast skin problems Yes No
Any family history of breast cancer Yes No Who:__________________________________
Any family history of ovarian cancer Yes No Who:__________________________________
When was your last mammogram __________ Where was it done ________________________
*** FOR OFFICE USE ONLY***
HT________________________ WT_________________
BP______________ P____________ R___________ T___________
___________________________________
Physician Signature/PID
___________________________
Date/Time
Mark J. Adler, MD
Rupa Subramanian, MD
Fareeha Siddiqui, MD
Lynette Cederquist, MD
Chris Lewis, PA-C
Scott Shuford, NP
D3267 (6-13) Page 4 of 5
Daniel Vicario, MD
Derek Helton, MD
Anjali Bharne, MD
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AUTHORIZED
INDIVIDUALS FORM
Patient Identification
Please list all individuals that are authorized to receive your medical information either verbal or
written.
NAME PHONE RELATIONSHIP
_____________________________________________
Signature of Patient
_______________________________________
Print Name
__________________________
Date/Time
Thank You!
D3267 (6-13) Page 5 of 5