JOURNAL TRANSCRIPT
PINNACLE HEALTH BREAST CARE CENTER 4300 Londonderry Road, Suite 202 Harrisburg, PA 17109 (717) 545-5000 (717) 545-5002 Fax
Dear ____________________________, Thank you for choosing the Pinnacle Health Breast Care Center. Your appointment has been scheduled with Dr. Lisa Torp / Dr. Brynn Wolff / Margaret Hummel, CRNP on __________________________________. Please arrive at ___________________________. In order to ensure that your appointment goes as smoothly and efficiently as possible, please complete the enclosed questionnaires, and bring them along to your appointment, along with your insurance cards. Filling out the initial paperwork prior to the day of your appointment enables you to give a more complete and detailed history and helps us to stay on schedule. If you have any questions about the paperwork or need any assistance, please feel free to call our office at 717.545.5000. We will gladly help in any way we can. Also, it is your responsibility to have an insurance referral sent to our office if required by your insurance. Please check with either your family care physician or your insurance carrier prior to your appointment to see if a referral is required. Keep in mind that most family care physicians require at least a 72-hour notice to provide referrals. Copayments will be collected prior to your appointment. Failure to pay the copay will result in the appointment being rescheduled. As breast surgeons, we do require that you bring the last five years worth of mammograms and any breast ultrasound films with you to your appointment. Therefore, you will need to call your imaging facility at least 48-72 hours prior to your scheduled appointment, so they can prepare your films for you to pick up. We are able to view some facilities images online; however, for your first visit with us, you MUST bring the films. If you do not bring the films, we have the right to reschedule your appointment to a later date. Additionally, please bring your calendar or day planner in case we need to schedule any further appointments for you. We realize your time is valuable, as is ours. If you need to reschedule or cancel your appointment, please notify us as soon as possible to avoid being charged for the missed appointment. Thank you again for choosing the Pinnacle Health Breast Care Center. We look forward to working closely with you to maintain your breast health. Sincerely, Lisa Torp, M.D., FACS
Form 1419-05 (12/12) InD
Brynn Wolff, M.D.
Margaret Hummel, CRNP
PINNACLE HEALTH BREAST CARE CENTER
DATE ______________________
The following information is very important to your health. Please complete all pages.
Name:________________________________________ Date of Birth:________________ Age:______ By what name would you like to be called?_________________________________________________ Reason for visit:______________________________________________________________________ Family Doctor:___________________________________Phone:_______________________________ Gynecologist:____________________________________Phone:_______________________________ Who referred you?____________________________________________________________________ PERSONAL BREAST HISTORY Have you had breast cancer in the past? Have you had prior breast biopsies? Year of biopsy:__________Side: Year of biopsy:__________Side: Have you had a breast reduction? Do you have breast implants?
Y Y R R Y Y
N If yes, when:_______________Side: R L BOTH N If yes, complete the following. L BOTH Diagonsis:___________________________ L BOTH Diagonsis:___________________________ N If yes, when:________________________________ N If yes, when:__________ Reason:______________
REPRODUCTIVE HISTORY Age at first menses:__________Date of last menses: __________Are you currently pregnant: Y N Number of pregnancies: ______No. of live births: ____________ Your age at birth of first child: _____ Have you gone into menopause? Y N If yes, have you taken hormones after menopause? Y N What hormones have you taken?_________________________________________________________ Length of time postmenopausal hormones have been used: __________How long ago? _____________ Have your ovaries been removed? Y N If yes, how old were you?__Which ovaries? R L BOTH FAMILY HISTORY List any blood relative who has had breast cancer and her/his age when diagnosed:_________________ ___________________________________________________________________________________ List any blood relative who has had ovarian cancer and her/his age when diagnosed:________________ ___________________________________________________________________________________ List any blood relative who has had colon/intestinal cancer and her/his age when diagnosed:_________ ___________________________________________________________________________________ Are you of Ashkenazi Jewish descent? Y N Please check all that apply. Mother Father Sister (s) Brother (s) Daughter (s) Son (s) Mother’s mother Mother’s father Father’s mother Father’s father Form 1419-05 (12/12) InD
Cancer
Type
(of cancer)
High Blood Pressure
Heart Attack
Diabetes
Stroke
Bleeding/ Clotting Problems
PATIENT NAME:__________________________________________ DOB:_____/______/________ MEDICAL/SURGICAL HISTORY List ALL prior operations and the dates of surgery: __________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ List any non-surgical hospitalizations within the past 2 years, giving dates and reasons: ____________________________________________________________________________________ ____________________________________________________________________________________ Have you been diagnosed with any infectious diseases within the last six months? (ex AIDS, HIV, No
MRSA, C-diff)
Yes
If so, what? __________________________
ANESTHETIC HISTORY Describe any problems that you have had with anesthesia: _____________________________________ ____________________________________________________________________________________ Describe any problems that a blood relative has had with anesthesia: ____________________________ ____________________________________________________________________________________ SOCIAL HISTORY Do you smoke? Y N If yes, # of packs per day?________# of yrs_____ Do you drink alcoholic beverages? Y N If yes, how much per day?___________________ Do you have a history of drug addiction? Y N If yes, what substance?______________________ Do you drink caffeinated beverages? Y N If yes, how many cups per day?_______________ Do you have supportive family/friends/ partner in case of illness? Y N Do you have a living will? Y N If yes, please provide a copy for your chart. If no, you may wish to discuss this with your family doctor. Do you have a durable power of attorney? Y N If yes, please provide a copy for your chart. ALLERGIES If you are allergic to any medications, over the counter and herbal meds, and food, list the item AND the type of reaction (hives, rash, etc): Medicine or food: Reaction: _________________________________________ _________________________________________ _________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
If you are allergic to any of the following items, please circle it: TAPE Form 1419-05 (12/12) InD
IV CONTRAST DYES
LATEX
BETADINE
SHELLFISH
PATIENT NAME:__________________________________________ DOB:_____/______/________ GENERAL HEALTH HISTORY Please circle all problems/symptoms which you are currently experiencing or have been treated for.
General:
Skin:
Vascular:
Endocrine/Metabolic:
Fatigue Weight loss Weight gain Fevers
Melanoma Psoriasis Skin cancers Rashes
High blood pressure Phlebitis / Blood clots Circulation problems Leg swelling
Diabetes Adrenal gland problems Thyroid problems High cholesterol
Pulmonary:
Cardiac:
HEENT:
Hematologic:
Asthma Emphysema COPD Chronic bronchitis Shortness of breath Tuberculosis Occupational dust exposure Cough
Heart attack Angioplasty Chest pain / Angina Irregular heart beat Atrial fibrillation Congestive heart failure Rheumatic fever Heart murmur Mitral valve prolapse
Hearing problems Dentures Capped teeth Difficulty swallowing Vision correction Blurred vision Glaucoma Macular degeneration Cataracts
Bleeding problems Easy bruising Anemia Idiopathic Thrombocytopenia Purpura von Willebrand’s Disease Factor V Leiden Hemophilia
Gastrointestinal:
Urological/Genital:
Musculoskeletal:
Immune System:
Ulcers / gastritis Reflux / heartburn Nausea/vomiting Colitis Hiatal hernia Hepatitis Jaundice Liver disease Pancreatitis Blood in stools Neurologic:
Kidney failure Dialysis Kidney stone Incontinence Difficulty voiding Endometriosis Ovarian cyst / tumor Abnormal PAP smear Sexually Transmitted Disease Psychological:
Arthritis Joint replacements Metal plates or screws Osteoporosis Osteopenia Chronic neck / back pain Muscle disease Fibromyalgia Muscle aches/pains
Lupus Scleroderma Sarcoidosis Rheumatoid Arthritis Immune System Disease (AIDS)
Stroke / TIA Seizure Weakness Numbness Paralysis
Depression Anxiety disorder Schizophrenia Dementia Alzheimer’s Sleep disorder
List any prior cancers and date of treatment: ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________
NO CURRENT SYMPTOMS/PROBLEMS The information supplied on these forms is true and correct to the best of my knowledge.
_________________________________ ________________ _________________ _______________ Patient Signature Date Staff Initials Date Form 1419-05 (12/12) InD
CURRENT LIST OF MEDICATIONS TAKE BY PATIENT LIST ALL PRECRIPTION MEDICATIONS, OVER THE COUNTER MEDICATIONS, VITAMINS, AND HERBAL SUPPLEMENTS BELOW. PLEASE PRINT. PATIENT NAME:____________________________________DATE OF BIRTH:_______________ Medication Allergies: Medication: Medication: Medication: Medication: Medication: Medication: Medication: Medication: Medication: Medication: Medication: Medication:
Dose (mg): Taken how often: What condition does this treat? Dose (mg): Taken how often: What condition does this treat? Dose (mg): Taken how often: What condition does this treat? Dose (mg): Taken how often: What condition does this treat? Dose (mg): Taken how often: What condition does this treat? Dose (mg): Taken how often: What condition does this treat? Dose (mg): Taken how often: What condition does this treat? Dose (mg): Taken how often: What condition does this treat? Dose (mg): Taken how often: What condition does this treat? Dose (mg): Taken how often: What condition does this treat? Dose (mg): Taken how often: What condition does this treat? Dose (mg): Taken how often: What condition does this treat?
Date discontinued / / Date discontinued / / Date discontinued / / Date discontinued / / Date discontinued / / Date discontinued / / Date discontinued / / Date discontinued / / Date discontinued / / Date discontinued / / Date discontinued / / Date discontinued / /
PATIENT SIGNATURE_________________________________________DATE______________________ PHARMACY NAME (Both mail-away, if applicable, and local pharmacies) PHONE NUMBER ___________________________________________________________________________________________ ___________________________________________________________________________________________ Form 1419-05 (12/12) InD
From Route 83 North (Hershey, West Shore, York)
I-83 North to Exit 48 (Union Deposit Road) Right off ramp onto Union Deposit Road Left onto Scenery Drive (First red light) Left onto Old Union Deposit Road Right onto Avilla Road Left on to Londonderry Road Right on to John Bonitz Drive Medical Science Pavilion is a separate building between hospital entrance and Emergency Room
From Route 81 North (Carlisle, Enola, Chambersburg, Route 11/15)
I-81 North to I-83 South I-83 South to Exit 48 (Union Deposit Road) Left off ramp onto Union Deposit Road Left onto Scenery Drive (Second red light) Left onto Old Union Deposit Road Right onto Avilla Road Left on to Londonderry Road Right on to John Bonitz Drive Medical Science Pavilion is a separate building between hospital entrance and Emergency Room
From Routes 322/22 East
Routes 322/22 East (across Susquehanna River)to I-81 North I-81 North to I-83 South I-83 South to Exit 48 (Union Deposit Road) Left off ramp onto Union Deposit Road Left onto Scenery Drive (Second red light) Left onto Old Union Deposit Road Right onto Avilla Road Left on to Londonderry Road Right on to John Bonitz Drive Medical Science Pavilion is a separate building between hospital entrance and Emergency Room
From Route 81 South (Grantville, West Hanover, Annville)
I-81 South to I-83 South I-83 South to Exit 48 (Union Deposit Road) Left off ramp onto Union Deposit Road Left onto Scenery Drive (Second red light) Left onto Old Union Deposit Road Right onto Avilla Road Left on to Londonderry Road Right on to John Bonitz Drive Medical Science Pavilion is a separate building between hospital entrance and Emergency Room
Form 1419-05 (12/12) InD