Metrolina AIDS Project

PATIENT NAME: ______

LASTFIRSTMIDDLEPREFERRED NAME

Date of Birth: ______

Phone #s: Home ______Cell______Work ______

Reason for Referral: ______

Referring Provider: ______

Primary Care MD: ______

Other Providers seen in the past year: ______

Preferred Pharmacy: ______

Have you completed advanced directives (living will/health-care power of attorney)? ___ Yes ___ No

Personal Medical History

Please check which of the following conditions you have.

______colon polyps – how many? ______

______dementia/memory loss

______diabetes

______High blood pressure or heart disease

______skin lesions Please describe: ______

______stroke/blood clots

______thyroid condition

______Prior cancer diagnosis
if yes, what type of cancer? ______
Where were you treated?______

List any other medical problems you have had:

Medication
List all medications you are on (prescriptions, over the counter and herbal supplements)
Name of MedicinesDosageFrequency
______
______
______
______
______
Allergies: DrugReaction
______

______

Are you a smoker? ___Yes ____No _____Former Smoker:Quit date:______

If yes or former smoker:

Do/did you smoke: Cigarettes Cigars Pipe

How much do/did you smoke? ______packs per day

For how long have/did you smoke? ______years

Do you drink alcohol?YesNo

If yes, how much do you drink? ______

Do you use drugs (Marijuana or other type?) ____ Yes ___No

Surgical History

List any major surgeries, including cosmetic surgery. Check here if none. ______

Date Type of surgery

______

Health Maintenance/Cancer Screening History

List the cancer screening tests, if any, that you have undergone. Check here if none. ______

Date of most recentProcedure

______Mammogram/Breast Ultrasound -where ______

______Bone density

______Breast Biopsy – How many total biopsies have you had? ______

______Pap smear

______Endometrial biopsy

______CA-125

______Ovarian Ultrasound

______Sigmoidoscopy/Colonoscopy

______Fecal Occult Blood Test

Reproductive History

A. Hormonal History:

______How old were you when you had your first period?

______Have you ever used Birth Control Pills?

______If yes, how many years total did you take them?

______How old were you when you had your first child?

______Have you used any fertility drugs?

Describe type & duration ______

Are you pregnant now, or trying to get pregnant? ____Yes ___ No

Note: Cancer treatments may cause infertility. We work with doctors in the Fertility Clinic at UNC to help determine the risk of infertility after cancer treatments. New strategies are available before cancer treatments begin that may help preserve the opportunity to have a family in the future.

Would you be interested in learning more about the options to preserve fertility?  Yes  No

Are you still having periods?____Yes ____ No

Date of last period (LMP) ______

Are they regular? ___ Yes ____ No

______Have you ever used Estrogen or Hormone Replacement Therapy?

______If yes, how many years total have you taken them?

C. Gynecological History

Have you ever been diagnosed with any of the following conditions?

______Uterine Fibroids

______Ovarian Cysts

______Endometriosis

______Cervical Dysplasia/ abnormal pap smear

Do you still have your:

-UterusY / N

-OvariesY / N

Social History

Occupation: ______

Marital Status: ___Single ____Married ____Widowed ___ Divorced ___ Other: ______

Name of spouse or significant other: ______

Family History Questionnaire

Please fill in the following information about your biological family. Include information about all family members, not just the ones who have had cancer or those who have died. For those that have had cancer, we need to learn as much as possible. We would like to know the location or type of cancer and approximate age of diagnosis. This information is used to help determine risks and recommend screening protocols for early cancer detection. We realize you may not know all of this information, but do the best you can. It may help to talk with family members to gather some of this history.

Are you of Ashkenazi Jewish ancestry (Eastern European)? Y / N

Are you Hispanic?Y / N

Race (circle all that apply): African American/ Black

American Indian

Asian

Native Hawaiian/Other Pacific Islander

Unknown

White

Current age / Location/ type of cancer / Age at cancer diagnosis
Yourself
If you have ever had other cancers please list:

Please list information below about your children: Please list additional children/grandchildren on the back

Male or female? / Living?
Y / N / Current age/ age at death / Cancer?
Y / N / City of residence / Location/ type of cancer / Age at cancer diagnosis / # of grandsons / # of grand daughters
M / F / /
M / F / /
M / F / /
M / F / /
M / F / /

Please fill in the following information regarding your immediate family:

Relative / Living?
Y / N / Current age/ age at death / Cancer?
Y / N / Location/ type of cancer / Age at cancer diagnosis
Your Mother
Your Father

Please list information below about all of your brothers and sisters. Please indicate if they are not full biological siblings (same mother and father as you).

Male or female? / Living?
Y / N / Current age/ age at death / Cancer?
Y / N / Location/ type of cancer / Age at cancer diagnosis / # of sons / # of daughters
M / F / /
M / F / /
M / F / /
M / F / /
M / F / /
M / F / /
M / F / /
M / F / /

If you have additional brothers or sisters, or if any of your nieces or nephews have/had cancer, please list this information below or on the back.

Please fill in the following information regarding your mother’s side of the family:

Relative / Living?
Y / N / Current age/ age at death / Cancer?
Y / N / Location/ type of cancer / Age at cancer diagnosis
Grandmother
Grandfather

Please list information below about all of your mother’s brothers and sisters:

If you have additional aunts or uncles, or if any of your first cousins (the children of your aunts and uncles) have had cancer, please list this information below or on the back.

Please fill in the following information regarding your father’s side of the family:

Relative / Living?
Y / N / Current age/ age at death / Cancer?
Y / N / Location/ type of cancer / Age at cancer diagnosis
Grandmother
Grandfather

Please list information below about all of father’s brothers and sisters:

If you have additional aunts or uncles, or if any of your first cousins (the children of your aunts and uncles) have had cancer, please list this information below or on the back.

General / None  / Fever______Chills______Night Sweats______
Weight Change______Loss of Sleep______
Fatigue______if yes: does it affect your activities?______
Pain______if yes: where?______
Description? Stabbling __ Throbbing ___ Muscle Ache____ Cramping___
Eyes / None  / Glasses______Contacts______Change in Vision_____
Double Vision______Blurred Vision______Pain______
Ears, Nose, Throat / None  / Hearing Loss____Hearing aid______Ear Infections______
Ear drainage____ Ringing in Ears____Runny Nose______
Sinus Problems___ Nose Bleeding_____
Dental Problems____Dentures______Gum Disease_____
Painful or Difficulties Swallowing______Sore Throat______
Hoarse Voice______Mouth Sores______
Heart / None  / Irregular heartbeat_____ Palpitations____ Feet Swelling____
Chest Pain_____ Poor Circulation______
Lung / None  / Shortness of breath____ if so-at rest____walking___stairs___
Sleep on more than one pillow?_____if so- how many?______
Coughing____ if so- dry____or productive_____blood______
Stomach/
Bowel / None  / None____ poor appetite____nausea/vomiting_____ Heartburn______Ulcer______Hernia______
Liver disease______Yellow skin_____
Change is stool habits______Change in stool color______
Abdominal pain______Rectal bleeding______
Urine / None  / Dribbling urine______Incontinence______Pain with Urination______
Urinary Tract Infections/Kidney Infections______
Kidney disease______Blood in urine______
Breasts / None  / Lump______Pain______Nipple discharge______
Infection______Breast Dimpling______
Skin / None  / Rash______Skin Cancer______
Abnormal Moles______Psoriasis______Bruise easily______
Muscle and Bones / None  / Back Pain_____ Joint Pain_____ Arthritis______
Difficulties Walking______Gout______
Nervous System / None  / Seizure_____ Headaches______Paralysis____ Weakness______Fainting______Numbness______Forgetfulness______
Mental Health / None  / Anxiety_____ Depression______Phobias______
Hallucination______Suicidal Thoughts______
Hormones
/ None  / Diabetes______Thyroid problem______Hot flashes______
Blood/
lymph system / None  / Bleeding disorder_____ Blood transfusion(s)______Anemia______
Swollen lymph glands______Blood clots______
Immune System / None  / Steroid Use______Immune Disorder______
HIV______AIDS______Chemotherapy______

What questions do you have for your breast cancer team? ______

Medical Treatment is only part of your cancer journey. Equally important is the care your emotional, psychological, and spiritual wellbeing. Cone Health Cancer Center has a patient and family support team available to help you during your treatment. The Patient and Family Support Team includes a Social Worker, Chaplain, Dietician, and Psychologist. The Journey also has information about our patient and family support team, support groups, and resources in the community.

Please let us know if you would like more information or how we can best help you.