MEDICAL HISTORY QUESTIONNAIRE

929 SW Simpson Ave, Suite 300 Bend, OR 97702 Phone 541.389.7741 Fax 1.541.278.8375

MEDICAL HISTORY QUESTIONNAIRE Date: __________ Patient Name: _____

Author Dominick Rich

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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

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