Dear Patient:
This information is important for your healthcare; please fill it out carefully and completely. This will become part of your medical record; all information is strictly confidential. Thank you for your cooperation.

1. GENERAL CONDITION
   1. My current health allows me to: (choose the single most appropriate response)
      1. Be fully active and carry on all normal activity
      2. Perform activities such as light house work, office work, shopping, etc. but not to perform strenuous activities
      3. Take care of myself but not perform light work. I am out of bed more than half of the day and I get out of the house
      4. Stay pretty much at home, in a bed or a chair more than half of the day, but I'm able to take care of myself to some degree
      5. Be confined to a bed or a chair all the time
   2. With regard to pain, I'm having:
      1. No pain
      2. Mild pain, requiring little or no medication
      3. Moderate pain, requiring regular medication
      4. Severe pain, requiring regular strong pain medication such as narcotics
   3. My pain is: Adequately controlled Inadequately controlled
2. MEDICINES
   1. Are you currently taking medications (including over-the-counter medications and/or supplements)?

      Yes

      No

      If yes, list your current medications and/or supplements:

      	Drug	Dose	Frequency	Last Dose
      1.
      2.
      3.
      4.
      5.
      6.
      7.
      8.
      9.
      10.

      If you would like to establish Oncology RX as your preferred pharmacy, check here .
      Otherwise, please give the following information for your preferred pharmacy:
      
      Name:    
      Address:
      Phone:  
   2. Are you allergic to any drugs? Yes No
      Especially latex rubber, shellfish, or x-ray dye. I am allergic to:

      	Drug	Reaction
      1.
      2.
      3.
      4.

3. SURGERIES
   1. Have you ever had surgery? Yes No
      If yes, list your operations:

      Surgery	Year (approx.)	Surgery	Year (approx.)
      1.		5.
      2.		6.
      3.		7.
      4.		8.

   2. Have you been hospitalized? (Other than current problem or surgeries above) Yes No

      	Problem / Injury	Year (approximate)
      1.
      2.
      3.
      4.

   3. Do you have any chronic medical conditions? Yes No

      	Problem / Injury	Year of onset (approximate)
      1.
      2.
      3.
      4.
      5.

   4. Have you had radiation? Yes No

      	When	Amount
      1.
      2.

4. WOMEN ONLY
   1. I have had pregnancies and children.
   2. I'm still having menstrual periods. Yes No
      If yes:

      1. My last period was (date).
      2. My periods are Regular Irregular
      3. Have you had spotting or bleeding between periods? Yes No
      If no:

      1. I stopped having my menstrual periods at the age of .
      2. Have you had abnormal bleeding recently? Yes No
   3. Have you had an abnormal pap smear? Yes No
      If yes, when?
5. BLOOD TRANSFUSIONS
   Have you ever had blood transfusions? Yes No
   If yes, did you have a reaction? Yes No
   My most recent transfusion was (date).
6. ILLNESSES
   

   I have had the following illnesses:	Yes	No
   Measles
   Mumps
   Chicken Pox
   Shingles
   Tuberculosis
   Rheumatic Fever

7. HEALTH PROBLEMS Have you had any of the following health problems?
   

   	Yes	No			Yes	No
   Head injuries				Hepatitis
   Glaucoma				Gall stones
   Cataracts				Bowel disease
   Other eye problems				Pancreatitis
   (Specify)				Kidney stones
   Recurrent sinusitis				Prostate disease
   Nose diseases				Bladder disease
   Mouth diseases				Venereal disease
   Dental problems				Arthritis
   Throat diseases				Muscle disease
   Thyroid disease				Anemia
   Hearing loss				Bleeding disorder
   Pneumonia				Stroke
   Pleurisy				Seizure
   Pulmonary emboli (blood clots in lung)				Spinal cord problems
   Emphysema				Other neurologic problems
   Chronic bronchitis				Anxiety
   Asthma				Depression
   Heart problems				Insomnia
   Angina (chest pains)				Psychological problems
   Fluid around the heart				Sexual problems
   Ulcer disease				Other problems
   Liver disease				(specify)

8. FAMILY HISTORY
   My father is living / dead at age . His health problems include(d):
   
   My mother is living / dead at age . Her health problems include(d):
   
   I have brothers and sisters. Their ages are .
   Health problems include:
   I have children. Their ages are .
   Health problems include:
   Other than the above, there is cancer in the family as follows:
   Other diseases in the family are:
   
   Current living arrangements:
   Living alone with family members with friend(s)

   Do you have concerns you would like to discuss about:

   Transportation, home care assistance, health care expenses? Yes No

   Support groups, counseling? Yes No
9. SOCIAL HISTORY
   I currently do not work work as
   I previously did not work worked as
   Have you been exposed to chemicals? Yes No
   Specify:
   Do you currently smoke cigarettes? Yes No
   If yes, how many packs per day? When did you start smoking?
   Do you smoke cigars? Yes No If yes, how many? How long?
   Do you smoke a pipe? Yes No If yes, how many? How long?
   If you currently do not smoke, did you ever smoke? Yes No
   If yes, how much did you smoke? When did quit?
   Do you drink alcohol? Yes No If yes, please circle correct response:
   

   1.

   Occasionally

   2.

   Frequently

   3.

   Daily

   How many drinks per week?

   I have have not had significant "recreational" drug exposure.
   Have you recently traveled outside the U.S.? Yes No
   If yes, Where? Last date traveled
10. CURRENT SYMPTOMS
    Have you had any of the following in the past year?
    

    	Yes	No			Yes	No
    Headache				Palpitations
    Dizziness				Swollen veins
    Fainting				Swollen feet or legs
    Double vision				Nausea
    Blurry vision				Vomiting
    Blind spots				Vomiting blood
    Eye pain				Yellow eyes or skin (jaundice)
    Eye swelling				Belly pain
    Ear pain				Belly swelling
    Change in hearing				Diarrhea
    Ear discharge				Red blood in stool
    Change in nose breathing or stuffiness				Purple blood in stool
    Nose bleeds				Black tarry stools
    Mouth sores				White chalky stools
    Mouth pain				Green or yellow stools
    Mouth bleeding				Back pain
    Swollen lymph nodes				Difficulty urinating
    Stiff neck				Pain during urination
    Skin rash				Frequent urination
    Skin tumors				Pus in urine
    Other skin changes				Blood in urine
    Cough (dry)				Problems with bladder or bowel control
    Cough up blood				Feeling cold
    Cough up phlegm				Feeling hot
    Shortness of breath at rest				Seizures or fits
    Shortness of breath with exercise				Personality change
    Shortness of breath at night				Memory loss
    Shortness of breath while lying flat				Numbness or tingling
    Pain on deep breathing				Loss of strength in specific areas of the body
    Fever				Decreased coordination
    Chills				Speech problem
    Sweats				Other problems (specify)
    Chest pain