Medical History printable form - PDF - PDF by tqd15644

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									                                                       My Medical History

Name __________________________________________________________________ Date of birth ___________________
Recent cancer diagnosis ________________________________________________ Date of diagnosis _______________
Allergies/reaction __________________________________________________________________________________________
Emergency contact _____________________________________________________________ Tel: (                             ) ______________
Surgeon _____________________________________________________ Tel: (               ) _____________ Fax: (          ) _____________
Primary doctor _________________________________________________ Tel: (            ) _____________ Fax: (          ) _____________
Medical oncologist ____________________________________ Tel: (                     ) _____________ Fax: (          ) _____________
Radiation oncologist ____________________________________ Tel: (                   ) _____________ Fax: (          ) _____________
Other doctor _________________________________________ Tel: (                      ) _____________ Fax: (          ) _____________
Pharmacy ____________________________________________ Tel: (                       ) _____________ Fax: (          ) _____________
Do you have Advance Directives:         No     Yes          kept in (location) __________________________________________
My designated agent’s name and telephone number ______________________________________ (                            ) _____________
Date of immunizations:             Tetanus _________________ TB skin test _____________ Flu shot __________________
                                   Pneumonia vac ___________ Hepatitis ________________ Others ___________________
Date of tests:                     Mammogram ____________ Bone density _____________ Pelvic exam ______________
                                   Pap smear ______________

Medical Problem(s) Encircle the problem for yes answer

Other cancer/date            Lung                       Abdomen                     Bladder                    Anxiety/depression
_________________________    Asthma/bronchitis          Abdominal swelling          Low back pain
                                                                                                               Weight loss _______ lbs
_________________________    Chronic cough              Blood in the stool          Bladder infection
                                                                                                               Over what time period:
                             Emphysema pneumonia        Constipation/diarrhea       Blood in the urine
Cardiovascular                                                                                                 _________________________
                             Tuberculosis               Gall Bladder                Frequent urination
Anemia
                             Did you or do you smoke    Heart burn/ulcer            Kidney infection           Current symptoms
Bleeding easily
                              No                        Hepatitis _______                                      bothering you
Blood clots (phlebitis)                                                             Others
                              Yes      pack/yr______    Nausea/vomiting                                        _________________________
Chest pain                                                                          Convulsion/seizure
                                                        Ulcer                                                  _________________________
Dizzy/fainting spells        Musculoskeletal                                        Diabetes
                                                                                                               _________________________
Heart attack/failure         Arthritis                                              Hypothyroidism
                                                                                                               _________________________
High blood pressure          Bone/joint pain                                        Hyperthyroidism
Stroke                       Osteoporosis                                           Leg pain/leg swelling


Gynecology History

Age at first menstrual period _____________ Age at menopause _____________ Age at first live birth ______________
Number of pregnancies __________________ Number of live births ___________ Total months of breast feeding ______
Hysterectomy       No       Yes   , age ________ Were ovaries removed too?           No     Yes
Hormone therapy:                                                  a. Birth control pills   No     Yes       Total months/years _____
b. Estrogen        No       Yes      Total months/years _____ c. Progesterone              No     Yes       Total months/years _____


Past Surgeries or Invasive Procedures/Date

 _______________________________________________________________________________________________________
 _______________________________________________________________________________________________________
                                                                                                                                                                                                                                                                                                                          My Family History

                                                                                                                  Living?                                                                                                                                                                                            Medical History Please circle appropriate history
Relation/Name
                                                                                                                  Yes (age) No                                                                                                                                                                                       C (cancer), CV (heart problem), D (diabetes), S (stroke)




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                                                                                                                                                                                                                      ............................................................................................
Paternal grandfather                                                                                                                                                                                                                                                                                                 C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Paternal grandmother                                                                                                                                                                                                                                                                                                 C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Maternal grandfather                                                                                                                                                                                                                                                                                                 C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Maternal grandmother                                                                                                                                                                                                                                                                                                 C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Father                                                                                                                                                                                                                                                                                                               C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Mother                                                                                                                                                                                                                                                                                                               C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Maternal aunt                                                                                                                                                                                                                                                                                                        C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Maternal uncle                                                                                                                                                                                                                                                                                                       C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Paternal aunt                                                                                                                                                                                                                                                                                                        C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Paternal uncle                                                                                                                                                                                                                                                                                                       C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Brother                                                                                                                                                                                                                                                                                                              C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Brother                                                                                                                                                                                                                                                                                                              C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Brother                                                                                                                                                                                                                                                                                                              C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Sister                                                                                                                                                                                                                                                                                                               C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Sister                                                                                                                                                                                                                                                                                                               C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Sister                                                                                                                                                                                                                                                                                                               C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

1st degree cousin                                                                                                                                                                                                                                                                                                    C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

1st degree cousin                                                                                                                                                                                                                                                                                                    C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

Children:                                                                                                                                                                                                                                                                                                            C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

                                                                                                                                                                                                                                                                                                                     C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

                                                                                                                                                                                                                                                                                                                     C      Type: ________________________________ Age at diagnosis ______
                                                                                                                                                                                                                                                                                                                     CV     D      S     Other:

								
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