EMERGENCIES CALL 911
Date of Birth: Email:
All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
Please list all prescriptions, vitamins, herbs, and over-the-counter medications that you are currently taking and/or bring your
Medications with you to your appointment.
(If additional space is needed please copy this page)
Have you ever had an allergic reaction to:Contrast DyeIodineShell Fish
What type of reaction did you have:HivesShortness of breathOther
Have you ever had any of the following symptoms or diseases?:
Seizures :YesNoThyroid Disease:YesNo
Tuberculosis:YesNoShortness of Breath:YesNo
Heart Failure:YesNoChest Pain:YesNo
Heart Murmur:YesNoHigh Blood Pressure:YesNo
Breast Mass/Cyst:YesNoStomach/intestinal ulcers:YesNo
Bladder Infections:YesNoVaginal Infections:YesNo
Blood clots in legs:YesNoHepatitis:YesNo
Cancer:YesNoBlood in Urine:YesNo
Blood in stool:YesNoFrequent urination:YesNo
Change in stools :YesNoBlack tarry stools:YesNo
Change in weight:YesNoSwelling in legs/feet :YesNo
Has anyone in your family ever had any of the following diseases? If yes, list their relationship to you:
High blood pressure
Is there anything else in your health history that you feel I should know?:
List any surgeries, the date, and hospital where the surgery was performed:
Review of Symptoms
General:Weight loss/gainEnergy LevelFatiguePoor AppetiteNight Sweats
Eyes:Blurred visionDouble visionCataractsGlaucomaSpotsOther
Ear, Nose & Throat:Nose BleedsStuffy NoseSinusitisDifficulty Chewing FoodDifficulty SwallowingDenturesHoarseness
Emotional Status:NervousTearfulDepressedChange in sleeping patternOther
Gento-Urinary System:BurningDark or bloody urineStonesInfectionColonoscopyConstipation
Women:Irregular periodsMissed periodsHot flashesLast pap smearLast mammogram
Men:Prostate problemsLast prostate examLast PSA testHow many times do you urinate at nightOther
Respirations:CoughWith sputumWith bloodChest painWheezingOther
Cardiovascular:Chest pain with effortCholesterolHeart ProblemsHypertensionShortness of BreathHeart AttackStrokeAngina
Joints and Muscles:Joint painBack painOtherSwollen joints, where
What makes it:BetterWorse
Patient Signature:[signature PatientSignature]Date:
Reviewed with patient by:
Physician Signature:[signature PhysicianSignature]Date:
PATIENT CONFIDENTIALITY QUESTIONAIRE
1) Please list the family members or other persons, if any, that we may inform about your general medical condition and your diagnosis:
2)Please list the family members or significant other, if any, that we may inform about your medical condition ONLY IN AN EMERGENCY:
3)Please print where you would prefer to have your billing statement and/or correspondence from our office sent if other than your home address:
City: State: Zip Code:
4)Please print the name of the person (if other than self) and phone number where you would like to receive phone calls concerning your appointments, labs, radiology results, or other health information if other than your home phone number.
Can confidential messages (i.e. appointment reminders) be left on your telephone answering machine?
Patient/Guardian Signature:[signature PatientGuardianSignature] Date:
Date of Birth:
According to our Notice of Privacy Practices, we may release your health information, including information about your condition to a family member or friend who is involved in your medical care or who helps you pay for your car. If you would like us to refrain from releasing your health information to a family member or friend, please list the name(s) of who you DO NOT want your private health information released to on the lines below. Remember, in the future, if there are additions to this list, please notify the University Cancer Diagnostic and Treatment Clinics staff. This authorization will remain in effect until revoked by you in writing. Thank you.
Patient Signature:[signature PrivacyPracticessignature] Date:
Welcome to University Cancer Diagnostic and Treatment Clinics. We appreciate the opportunity to provide you with the highest quality care available. If you have any questions or concerns, ask and we will do our best to give you a response as quickly as possible.
Also attached are:
a Patient Confidentiality Questionaire for you to tell us who, if anyone, you would like to have access to your confidential records
a Medical History Questionaire for you to tell us about your past and present health
and an Assignment of Benefits form for you to provide us information concerning issures about financial responsibility of your services
Please review and complete all attached forms to the best of your ability and bring with you to your appointment or hand in to front desk.
To avoid scheduling delays and ensure that we can correctly assess your condition, please ask your referring physician to provide us with all necessary medical records, pathology reports and insurance referral forms (if applicable) prior to your appointment.
Again, if at any time you have questions, concerns or problems let us know. We will make every effort to address your situation in the most satisfactory manner as possible.
University Cancer Diagnostic and Treatment Clinics