PATIENT HISTORY FORM

Date: _______/_________/________
NAME: Birthdate: _____/______/_____
Last First M. I.
Age:___________ Sex:  F  M

Reason for Consultation

History of Present Illness

Cancer History
Do You have a current or past diagnosis __ Yes ___ No
of cancer?
Type of cancer and Stage
Age at first Diagnosis
Treatments Received? __ Yes __ No if yes:
Treatment Received Date Started and Finished Dose/ Cycles Done

Have you ever had any other cancers, ___ Yes ___ No
either current or past?
Cancer Age at Diagnosis

SYSTEMS REVIEW
Pain ___ yes ___no
If yes, where: ___________ Intensity __________________ Frequency ____________
GENERAL
 Weight gain; how much Weakness
Recent weight loss: how much____ Fever
Tiredness: How much time do you spend in bed? Chills
__ <25% Night Sweats
__ 25-50%
__>50%
SKIN, HAIR, NAILS, BREAST
Pale Spontaneous bruising
Jaundice Frequent skin infections
Ruddy facial complexion Change in hair texture, color, distribution
Itching Change in nail texture
Blotchy rash Breast pain
Easy bruising Nipple discharge
EYES
Blind Double vision
Recent change in eyeglass prescription Blind spots
Blurry vision See rainbow, flashes, floaters
Dryness Eye pain
EARS
Deafness Ear pain
Difficulty hearing Ringing
Discharge
NOSE
Stuffiness Bleeding
Discharge Frequent Colds
Sneezing Sinus Pain
THROAT
Sore throat Hoarseness
Change in voice Lump in throat
RESPIRATORY
Cough Shortness of breath at rest
Sputum production Shortness of breath on exertion
Blood in sputum Wheezing
Sharp or stabbing chest pain worse when inhaling
CARDIAC
Palpitations Murmur
Pressure sensation in your chest Swelling of arms
Chest pain at rest Swelling of legs
Chest pain at exertion Pain in calf muscles at rest
Shortness of breath when lying down Pain in calf muscles when walking
Need to sleep propped on pillows Varicose Veins
GASTROINTESTINAL
Change in eating habits or diet Constipation
Distension Diarrhea
Indigestion Nausea
Abdominal pain or cramps Vomiting
Gaseousness Blood in stool
Fatty food intolerance Hemorrhoids
Hernia
GU AND VD
Trouble holding urine Loss of bladder control
Pain upon urination Hx of kidney stone
Get up more than once during the night to empty bladder Hx of UTI
Difficulty emptying your bladder Ulcers in genital and or rectal area
Bleeding or discharge Impotence
ENDOCRINE
Bulging in the front of your neck Increased thirst
Bulging eyes Increased urination
 Heat or cold intolerance Excessive sweating
HEMATOLOGIC/ LYMPHATIC
Spontaneous bleeding Transfusion history
Muscle weakness Pain in fingers or toes swelling
Craving for eating ice or crunchy foods Axillary Lymph
Pain on left upper abdominal areas Groin Lymph
Excessive bleeding with cuts or with tooth extraction Neck Lymph
MUSKULOSKELETAL
Muscle weakness Bone pain
Muscle wasting Joint swelling
Muscle pain Limitation of motion
Deformity of joints
NEUROLOGICAL
Pain where? Difficulty with coordination
Pins/needles sensation where? Difficulty walking
Paralysis Change in speech
Fainting Difficulty with memory of recent events
Seizure Headaches
Tremors Dizziness
Transient paralysis or weakness of limbs Lightheadedness
where?
Transient blindness
DIET
Want to speak to a dietician Problems chewing or swallowing
Poor appetite Mouth sores, taste changes
Problems preparing or obtaining meals Food intolerance (indicate)
Unintentionally lost more than 10 pounds in the past 3 Using supplements
months
Are you on a special diet? (indicate)

PSYCHOLOGICAL
Change in sleep pattern Difficulty with memory or concentration
Difficulty sleeping?
Difficulty falling asleep?
Thoughts of harming self Not enjoying life
Hearing voices or seeing things that others don’t Increasing desire to be alone
Having problems with spouse Change for the worse in my relationship with
others
Having problems with children Change in sexual interest or function
Feeling of worthlessness or guilty Sad/ Depressed/ Tearful
Thoughts of harming self

Personal Medical History (Check All That Apply and Time of Diagnosis)
Condition Date of Diagnosis Condition Date of Diagnosis
Anemia High Blood Pressure
Arthritis Kidney disease
Asthma Liver Disease
Blood Disorder/ Coagulopathy Mental Illness
Diabetes Migraine Headaches
Emphysema/ COPD Pneumonia
Epilepsy STD Specify____
Asbestos Exposure Sleep Apnea
Heart Disease Stroke
Type:
Hepatitis Type___ Thyroid Disease
Tuberculosis Tuberculosis
Ulcer Allergy to Medications (indicate
 what medication and type of
reaction)

Allergy Others

History of Blood Transfusion

Have you ever had a blood transfusion? ___Yes ______No
If Yes, did you have a reaction? Yes_____ No_____
Date of Last Blood Transfusion ______________

History of Hospitalization/ Surgery

Date Reason Where Doctor/ Attending Physician

Have your ever been advised to have surgery which was not performed? (Then State Reason)
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Previous Treatment for Cancer (if applicable)

Dose and/ or Cycles Indication Outcome
Radiation Therapy
Chemotherapy
Hormone Therapy

Ancillary Tests Done

Test Date Result

Current Medications Other Than Cancer Medications

Include Rx, OTC, Herbals, Supplements, Vitamins
Medication Dose Frequency Indication

Birth and Childhood History

Are you born ___ Term or ____ Preterm?
If preterm, indicate AOG and cause of preterm delivery: ___________
Have you been treated for any congenital disease when you were a child? ___ Yes ___ No indicate: _________
Have you undergone any surgery when you were a child or an infant? ___ Yes ___ No indicate: _______
Immunization History (include date of last vaccine if known)
Chickenpox Hepatitis B Pneumococcal Smallpox
Flu Measles Polio Tetanus

Family History (include age of diagnosis + stage or if in remission)

Grandfather Grandmother Parents Siblings Children
Paternal Maternal Paternal Maternal Father Mother Brother Sister Son Daughter
Ancestry/
Race
Age/ Age of
Death
Cause of
Death
Breast
CANCER
Ovarian
Colon
Lung
Prostate
Other
(indicate)
High Blood
Pressure
Heart
Disease
Stroke
diabetes
Bleeding
Disorder
Other

Other Family Members Diagnosed with Cancer (e.g. uncles, aunts, cousins)
Relationship Living? Cancer Diagnosis Age Cancer Diagnosed Current Age or Age of
Death

Exposure History (indicate history to toxin, radiation,

Exposure Date of Exposure Place of Exposure

Obstetric History
How many times have you been pregnant? _______ How many live births have you had? ________
Your age at the birth of your first child _____
Complications during pregnancy? ___ Yes ___ No History of miscarriages or abortions? ____________
How old are you when you began to menstruate? _______
Are you still having periods?
___ YES ____ NO
When was the first day of your last period?___ How old are you when you stopped having periods? _____
Usual Duration of Flow ___ are you experiencing bleeding after menopause?
Period occurs every _____ days ___ Yes __ No
Menstrual Symptoms
___ Menstrual Pain
___ Bleeding between periods
___ Spotting between periods
___ Excessive bleeding
Are you using any birth controls? ___ Yes ___ No What type of birth control? _______
If no, have you used any birth controls in the past? _____ Type Started Stopped and Reason
If yes, indicate what type/s, when it was used, when it was
stopped and why it was stopped
Type Started Stopped and Reason

Do you wish to become pregnant? ____ Yes ____ No

Date of Last Pap Smear_____ Have you had an abnormal Pap Test? _____ Yes ____No
Date of Last Mammogram ____ Treatment(s) received: _____________
Date of Last Colonoscopy
Sexual History
Are you sexually active? ____Yes ___ No How old were you when you had your first sexual contact?
_______
How many sexual partners have you had? ______ Sexual Preference: _________

Personal and Social History

Religion Type of Religion:
Any religious belief that need to be considered in planning care? __Yes ___ No (if yes, indicate)

Level of Education
Marital Status __ Single __Married __Domestic Partner __Divorced __Widowed
if married or with partner, what is the occupation? _____
Children Do you have Children? ___Yes ___No
If yes, how many children_____
Occupation ___________________
(previous if retired) Retired? ___ Yes ___No
Living Conditions With whom do you live? _____________
Have you served in the military? __Yes ___No If yes, dates of service_________
Do you have an advance directive? ___Yes ___No
Dietary History and Physical Activity
Food preference: _________
Mode of acquiring food? ____Cooked ____Bought
Fast food/ junk food frequency ______________
What do you do for exercise? ____________________ How many times a week? ___________

Smoking, Substance Abuse and Alcohol History

Smoking History
Do you currently use tobacco products? Type (indicate use per day) ___Cigarette ___Cigar
__Yes ___Pipe ___E-cigarette

For how many years have you used the above tobacco
product? ______
__ No Have you ever used tobacco products in the past?
___Yes ___ No

Type (indicate use per day) ___Cigarette ___Cigar

___Pipe ___E-cigarette
When did you quit? ________
For how many years have you used the above tobacco
product? ______
Alcohol Intake History
Do you drink alcohol? __ Yes ____No
Type of Alcoholic Beverage: ___________
How many drinks do you have in the average week? ___________
Have you drunk heavily? ___Yes ___ No?
If yes, how much and when did you stop? __________
Illicit Drug Use
Have you used illicit drug? ___ Yes ___No
If yes (refer to next page)

SUBSTANCE USE CHECKLIST

DRUG CATEGORY
(circle each substance used) Age when How much & How many When did Do you currently
you first how often did years did you you last use this?
used this: you use this? use this? use this?

ALCOHOL Yes □ No □
CANNABIS: Yes □ No □
Marijuana, hashish, hash oil
STIMULANTS: Yes □ No □
Cocaine, crack
STIMULANTS: Yes □ No □
Methamphetamine—speed, ice, crank
AMPHETAMINES/OTHER STIMULANTS: Yes □ No □
Ritalin, Benzedrine, Dexedrine
BENZODIAZEPINES/TRANQUILIZERS: Yes □ No □
Valium, Librium, Halcion, Xanax, Diazepam,
“Roofies”
SEDATIVES/HYPNOTICS/BARBITURATES: Yes □ No □
Amytal, Seconal, Dalmane, Quaalude,
Phenobarbital

HEROIN Yes □ No □
STREET OR ILLICIT METHADONE Yes □ No □
OTHER OPIOIDS: Yes □ No □
Tylenol #2 & #3, 282’S, 292’S, Percodan,
Percocet, Opium, Morphine, Demerol,
Dilaudid

HALLUCINOGENS: Yes □ No □
LSD, PCP, STP, MDA, DAT, mescaline,
peyote, mushrooms, ecstasy (MDMA),
nitrous oxide

INHALANTS: Yes □ No □
Glue, gasoline, aerosols, paint thinner,
poppers, rush, locker room
OTHER: (specify) Yes □ No □

PATIENT TREATMENT
YES NO MAYBE
Have you ever had to cope with a major illness of your own or a person close to you?
Do you know anyone who has received treatment for cancer?
Have you known anyone with an illness similar to yours?
Would you be interested in:
Individual supportive counseling during your treatment?
Counseling for family members to assist them in coping with your illness?
Participate in a support group?
Have you ever used relaxation techniques?
Do you want to have an advance directive?
Would you like information on:
Resources for educational materials
Community programs
Financial resources/ programs
Some people wish to know as much as they can about their illness and to make their own
decisions about their care. Others wish to know the basics and want their doctors to make the
appropriate choice. How do you feel?
What questions do you have reagarding treat,ment?
Functional Assessment of Cancer Therapy