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 Dye Iodine Shell Fish
What type of reaction did you have: Hives Shortness of breath Other
Have you ever had any of the following symptoms or diseases?:
Seizures : Yes NoThyroid Disease: Yes No
Tuberculosis: Yes NoShortness of Breath: Yes No
Asthma: Yes NoHeart Attack: Yes No
Heart Failure: Yes NoChest Pain: Yes No
Heart Murmur: Yes NoHigh Blood Pressure: Yes No
Breast Mass/Cyst: Yes NoStomach/intestinal ulcers: Yes No
Bleeding Disorder: Yes NoDiabetes: Yes No
Bladder Infections: Yes NoVaginal Infections: Yes No
Kidney Stones: Yes NoArthritis: Yes No
Blood clots in legs: Yes NoHepatitis: Yes No
Cancer: Yes NoBlood in Urine: Yes No
Blood in stool: Yes NoFrequent urination: Yes No
Diarrhea: Yes NoConstipation: Yes No
Change in stools : Yes NoBlack tarry stools: Yes No
Change in weight: Yes NoSwelling in legs/feet : Yes No
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/gain Energy Level Fatigue Poor Appetite Night Sweats
Eyes: Blurred vision Double vision Cataracts Glaucoma Spots Other
Skin: Itching Rash Sores Other
Digestion: Nausea Heartburn Indigestion Vomitting Diarrhea Constipation Hemorrhoids Bleeding Black Stools Other
Ear, Nose & Throat: Nose Bleeds Stuffy Nose Sinusitis Difficulty Chewing Food Difficulty Swallowing Dentures Hoarseness
Emotional Status: Nervous Tearful Depressed Change in sleeping pattern Other
Gento-Urinary System: Burning Dark or bloody urine Stones Infection Colonoscopy Constipation
Women: Irregular periods Missed periods Hot flashes Last pap smear Last mammogram
Men: Prostate problems Last prostate exam Last PSA test How many times do you urinate at night Other
Respirations: Cough With sputum With blood Chest pain Wheezing Other
Cardiovascular: Chest pain with effort Cholesterol Heart Problems Hypertension Shortness of Breath Heart Attack Stroke Angina
Joints and Muscles: Joint pain Back pain Other Swollen joints, where
Severity 1 2 3 4 5 6 7 8 9 10
What makes it: Better Worse
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