health questionnaire - Mount Sinai Hospital

M. BLOOD, INFECTIOUS & IMMUNE SYSTEM DISEASE HISTORY• Do you have a history of any of the following blood, infectious, or immune system problems?I have no blood, etc. problemsHepatitis B/C (HBV, HCV) HIV Anemia / low blood countsChicken Pox / Shingles Lupus(Have you ever received a blood transfusion? Yes No)Sickle cell disease / trait Scleroderma Thrombocytopenia / low plateletsFevers / Night sweats Eczema Hemophilia or other clotting disorder / easy bruising or bleedingUnintended weight loss Psoriasis Neutropenia / low white cells• Have you ever been placed on contact isolation orhad an antibiotic resistant infection? Yes NoN. GLAND DISEASE HISTORY• Have you had the following immunizations?Flu shot (date:________ )Pneumovax (date:_________)• Do you have a history of any of the following conditions?I have no gland problemsDiabetes Parathyroid disease Adrenal disease Carcinoid SyndromeHyperthyroidism Hypothyroidism Pituitary disease PheochromocytomaO. BONE, JOINT & SKIN DISEASE HISTORY• Do you have a history of any of the following bone, skin or joint problems?I have no bone, joint, or skin problemsBack pain / herniated disks / slipped disks Rheumatoid arthritis Chronic neck painOsteoarthritis / Degenerative Joint Disease Osteoporosis FibromylagiaScoliosis / Kyphosis / Spine abnormalities Ankylosing spondylitis KeloidsP. CANCER HISTORY• Have you ever had cancer? Yes NoIf you have had cancer, have you been treated with any ofIf yes, what type of cancer? _____________________ the following? Radiation Chemotherapy SurgeryQ. OTHER MEDICAL HISTORY• Please comment on any other relevant medical history not described above:The information provided is true to the best of my knowledge and I understand that it will be reviewed and modified foraccuracy as necessary by a member of the medical center staff.Name (Print) _______________________ Signature_________________________ Date/Time______________Fax Completed Form to 212-659-8328I have reviewed the information provided with the patient (or patient representative) and have verified, appended, and/or modified the informationfor accuracy as necessary.Reviewed By (Print)_________________________(RN) Signature___________________________________Date/Time_____________________MR 1588 (9/08) of 4