JOURNAL TRANSCRIPT
929 SW Simpson Ave, Suite 300 Bend, OR 97702 Phone 541.389.7741 Fax 1.541.278.8375
MEDICAL HISTORY QUESTIONNAIRE Date: __________ Patient Name: ________________________________________ DOB: __________
Age: ____
Please CIRCLE any of the conditions that you are experiencing TODAY. GENERAL/SYSTEMIC: □ □ □ □ □ □ □ □ □
Feeling tired General edema Chills Night sweats Recent weight loss Recent weight gain Difficulty falling asleep Snoring Daytime sleepiness
EYES: □ Vision problems □ Blurry vision
EAR/NOSE/THROAT □ □ □ □ □ □ □ □
Ringing in the ears (tinnitus) Loss of hearing Sinus pressure Nosebleeds recurrent Mouth sores Bleeding gums Hoarseness Difficulty swallowing (dysphagia)
NECK: □ Lump or swelling in the neck
GASTROINTESTINAL: □ □ □ □ □ □
Abdominal pain Nausea Vomiting Diarrhea Constipation Black or tarry stools (melena)
GENITOURINARY □ Incomplete emptying of the bladder □ Pain during urination (dysuria) □ Urinary frequency □ Urinary loss of control □ Pelvic pain □ Vaginal discharge □ Bloody or dark urine
ENDOCRINE: □ Excessive thirst □ Temperature intolerance to heat □ Temperature intolerance to cold
CARDIOVASCULAR: □ Chest pain or discomfort □ Palpitations
PULMONARY: □ □ □ □
Cough Coughing up blood (hemoptysis) Shortness of breath Wheezing
□ □ □ □ □ □ □ □ □
Numbness (hypoesthesia) Tingling Dizziness Headache Vertigo Tremors Fainting (syncope) Seizure Feeling weak
PSYCHOLOGICAL: □ □ □ □ □ □ □
Depression Anxiety Sleep disturbances Suicidal ideation Cry often Highly irritable Tense or under stress
DEPRESSION □ Depression recently □ Depression chronic
SKIN: □ Skin rash □ Itching (pruritus) □ Skin lesion
BREAST: □ Breast pain □ Breast lump □ Nipple discharge
NEUROLOGOCAL:
HEMATOLOGICAL: □ Easy bleeding
MUSCULOSKELETAL: □ □ □ □ □
Diffuse joint pain (arthralgias) Back pain Muscle pain Muscle weakness
SEXUAL □ Libido changes □ Unsatisfactory sexual interest □ Painful intercourse o Entry o Vagina o Deep o Other
GYNECOLOGY: □ Vaginal odor □ Vaginal itching or burning
□
ALL OTHERS NEGATIVE
NAME PCP
DATE OF BIRTH REFERRED BY
AGE
DATE OF SERVICE
PHARMACY
CC/HPI
REVIEW OF SYSTEMS - SEE SEPARATE FORM MEDICAL HISTORY Blood clots (leg/lungs) Stroke Headaches / migraines High blood pressure Diabetes Cancer: (type) Thyroid disease Heart disease / murmur Jaundice / hepatitis Digestive / bowel disorders Gallbladder disease Kidney disease
Yes [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]
No [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]
SURGICAL HISTORY Year Procedure
GYNECOLOGIC HISTORY Any abnormal PAP smear? Treatment for cervical dysplasia? DES exposure? Sexually transmitted infections?
Urinary tract infection High cholesterol Depression / anxiety Osteoporosis / osteopenia Arthritis Asthma / lung disease Breast disease Blood disorders / anemia Transfusion Neurologic disorder Skin disease Other
Year
Yes [ ] [ ] [ ] [ ]
Yes [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]
No [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]
Procedure
No [ ] [ ] [ ] [ ] Circle: chlamydia; gonorrhea; syphilis; herpes; HPV: genital warts; HIV; Hepatitis B; trichamonas
MENOPAUSAL Age of first period? Age of last period? Do you take hormones? Have you used hormones in the past? Do you have vaginal bleeding?
__________ __________ __________ __________ __________
PREGNANCY HISTORY Number of pregnancies Number of living children Number of term deliveries
__________ __________ __________
MENSTRUATING (if menopausal, omit) First day of last period? __________ Age of first period? __________ How often do you bleed? __________ How many days do you flow? __________ Do you spot between periods? __________ Are periods painful? __________ Are periods heavy? __________ Do you use any kind of birth control? __________ Type of birth control? __________
Reviewed by __________ Date__________ Done: JB__________ ALM __________ MA__________ Date __________
PREGNANCY HISTORY Number of pre-term deliveries (more than 3 weeks early) Number of adopted children Number of miscarriages / abortions Number of tubal pregnancies (ectopic) LIFE STYLE Do you exercise? Do you take a calcium supplement? Do you take a vitamin D supplement? Do you drink alcohol? Do you smoke? Have you ever smoked? Have you ever used IV drugs? Are you currently in a sexual relationship? Number of sexual partners ever? Have you changed sexual partners in the last 5 years? Is your sexual partner male or female?
Yes [ Yes [ Yes [ Yes [ Yes [ Yes [ Yes [ Yes [
] ] ] ] ] ] ] ]
No [ No [ No [ No [ No [ No [ No [ No [
Yes [ ] [ ] [ ]
HEALTH MAINTENANCE Last mammogram? Last PAP smear? Last cholesterol test? Colorectal cancer screening? (if >50 years old) Stool blood test? Colonoscopy? Bone density study? Pneumococcal vaccine? Tetanus booster?
Year __________ Year __________ Year __________ Year __________ Year __________ Year __________ Year __________ Year __________ Year __________
Yes [ ] [ ] [ ]
No [ ] [ ] [ ]
Heart disease? Diabetes? High blood pressure? Osteoporosis Stroke? Blood clots in legs / lungs? Thyroid disease? Drug / alcohol abuse? Mental disorders? Other?
[ [ [ [ [ [ [ [ [ [ [
[ [ [ [ [ [ [ [ [ [ [
MEDS / ALLERGIES - see problem list
] ] ] ] ] ] ] ] ] ] ]
] ] ] ] ] ] ] ] ] ] ]
Frequency? Type? How much? _______________________ How much? _______________________ How much? _______________________ How much? _______________________ How much? _______________________
Yes [ ] No [ ] Male [ ] Female [ ]
SOCIAL HISTORY Do you work outside the home? Is anyone hurting you? Has anyone ever sexually violated you?
FAMILY HISTORY Cancer?
] ] ] ] ] ] ] ]
No [ ] [ ] [ ]
Tetanus / pertussis Year __________ Shingles Year __________ Pneumovax Year __________ Meningococcal Year __________ Hepatitis B Year: #1 _______ #2 _______ #3 ______ HPV Year: #1 _______ #2 _______ #3 ______
Type (organ)? Who? ______________ ______________________________ ______________ ______________________________ ______________ ______________________________ Who? __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________
Cancer History Questionnaire ________________________________________ Date of Birth: ____________________________________ Gender: _________________ Health Care Provider: ____________________________________ Name:
Instructions: T his is a screening tool for cancers that run in families. Please mark (Y) for those that apply to YOU and/or YOUR FAMILY. Next to each statement, please list the relationship(s) to you and age of diagnosis for each cancer in your family. You and the following close blood relatives should be considered: Y ou, Parents, Brothers, Sisters, Sons, Daughters, Grandparents, Grandchildren, Aunts, Uncles, Nephews, Nieces, Half-Siblings, First-Cousins, Great-Grandparents and Great-Grandchildren __
You and your family’s Cancer History (Please be as thorough and accurate as possible) CANCER
YOU Age of Diagnosis
□ Y □
Example: Breast Cancer
Parents/Siblings/ Children
Age of Diagnosis
------
------
45
Relatives Maternal Side Aunt Cousin
Relatives Paternal Side
Age of Diagnosis
45 61
Grandmother
Age of Diagnosis
53
N
□ Y □
Breast cancer (Female or Male)
N
□ Y □
Ovarian cancer (Peritoneal/Fallopian tube)
N
□ Y □
Endometrial (Uterine) cancer
N
□ Y □
Colon/rectal cancer
N
□ Y □
10 or more Lifetime Colon/Rectal Polyps (Specify #)
N
□ Y □
Pancreatic cancer
N
□ Y □
Prostate cancer
N
□ Y □
Other Cancer(s) (Specify cancer type)
N
Are you of Ashkenazi Jewish descent? (circle one) YES NO Are you concerned about your personal and/or family history of cancer? (circle one) YES NO Have your or anyone in your family had genetic testing for a hereditary cancer syndrome? (Please explain/include a copy of result if possible) If Yes, Who? ________________________ What gene(s)? ______________________________ What was the result? __________________________________
BREAST CANCER RISK MODEL INFORMATION
HEREDITARY CANCER RED FLAGS
Your current height (ft/in) ______ Your current weight (lbs) ______ Your menopausal status:
Personal and/or family history of any one of the following
□ Pre-menopausal □ Peri-menopausal (time before menopause marked by irregular cycles) □ Post-menopausal: Age of onset ______
(check all that apply)
MULTIPLE: A combination of cancers on the same side of the family:
□ 2 or more: breast / ovarian / prostate / pancreatic cancer □ 2 or more: colon/rectal / endometrial / ovarian / gastric / pancreatic / other (i.e.,
(Permanent cessation of period for 12 months or longer)
Your age at time of first menstrual period ______ Your age at time of first live birth ______
Did you ever use Hormone Replacement Therapy? □ Y es If yes, type: □ Combined unknown
□ Estrogen only
ureter/renal pelvis, biliary tract, small bowel, brain, sebaceous adenomas)
□ No
□ Progesterone only
□ 2 or more: melanoma / pancreatic □
If yes, are you a: □ Current user: How many years ago did you start? Intend to use for ______ more years □ P ast user: How many years ago did you stop using? ______
Have you ever had a breast biopsy? □ Yes □ No If yes, do you know your diagnosis? ____________________ Number of daughters ______ Number of sisters ______ Number of maternal aunts (mother’s sisters) ______ Number of paternal aunts (father’s sisters) ______
(COMPLETE WITH YOUR HEALTH CARE PROVIDER)
YOUNG: Any 1 of the following at age 50 or younger:
□ Breast cancer
□ Colon/rectal cancer
□ Endometrial cancer
RARE: Any 1 of these rare presentations at any age:
□ Ovarian cancer (Peritoneal/Fallopian tube) □ Breast: Male breast cancer or Triple negative breast cancer (ER-, PR-, HER2- Pathology) Colon/rectal cancer with abnormal MSI/IHC, or MSI high associated histology††
□ Endometrial cancer with abnormal MSI/IHC □ 10 or more colon/rectal polyps* Certain ancestries such as Ashkenazi Jewish, may have greater risk for hereditary cancer syndromes
CANCER RISK ASSESSMENT REVIEW (To be completed after discussion with your healthcare provider)
Patient’s Signature
Date
Health Care Provider’s Signature
Date