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Academic year: 2021



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Patient Name: ___________________________________________________ MRN#


DOB: ____/____/____ Age: __________ Male Female SSN: ___________________________ Address: ________________________________________________________ Phone: (______)__________________

Cell Phone: (______)__________________

City:______________________________________________State:____________ Zip: __________________________

Secondary Address: ______________________________________________

City: ____________________________________________ State:_____________ Zip:_________________________ May we leave a message on your answering machine / voicemail? Yes No

Email Address:________________________________________ May we email you? Yes No

Preferred Language: __________________________________ ____________________________________________ Ethnicity/Race: White Hispanic/Latino Black/African American Native American Asian/Pacific Islander Other

Primary Care Physician: _____________________________________________ Phone #: ______________________ Referring Physician (if different):______________________________________ Phone #: ______________________ Please list any additional Physicians you see: (Include Phone #):

_________________________________________________________________ Phone #:_______________________

_________________________________________________________________ Phone #:_______________________

_________________________________________________________________ Phone #:_______________________

_________________________________________________________________ Phone #:_______________________

Emergency Contact Name: _________________________________________________________________________ Relationship:_____________________________________________________ Phone: (______)__________________

Power of Attorney(if applicable): ___________________________________Relation to You:_____________________ Living Will: Yes* No *Please provide a copy for your records


Reason For This Visit:______________________________________________________________________________ _________________________________________________________________________________________________

Medical History: (Check the items that apply to you, currently or in the past)

None Anemia Bleeding Disorder Blood Clots Blood Disorder Frequent infections HIV / AIDS Diabetes Thyroid Disease High Blood Pressure High Cholesterol Atrial Fibrillation

Congestive Heart Failure Heart Attack-MI

Heart Disease Rheumatic Fever Heartburn / Reflux Heart Murmur Irregular Heart Beat

Peripheral Vascular Disease


Chronic Lung (COPD) Pneumonia/Bronchitis TB (Tuberculosis) Sleep Apnea Colon Polyps Crohn’s Disease Diverticulitis

Irritable Bowel Syndrome Ulcerative Colitis Stomach Ulcers GERD/Heartburn Hiatal Hernia Gallstones Cirrhosis of Liver Hepatitis A/ B/ C Pancreatitis Kidney Stone Kidney Disease/Failure Freq. Urinary Tract Infections Enlarged prostate

Lupus-Autoimmune Reynaud’s Syndrome Rheumatoid Arthritis Osteoarthritis Chronic back pain Osteoporosis Fracture Stroke Neuropathy Parkinson’s Disease Paralysis Seizures Migraines Shingles Glaucoma / Cataracts Hearing loss Cancer Leukemia Lymphoma Anxiety Depression Drug Use

Problems with Anesthesia

Details of Medical History: __________________________________________________________________________

_________________________________________________________________________________________________ Cancer History:

Type: _________________________________________ Date diagnosed____________________________________

Treatment:(Type, Date, and location of treatment) ______________________________________________________ _________________________________________________________________________________________________


Past Surgical History: (Please circle and date any of the surgeries and/or procedures that you have undergone)

Coronary Bypass Date:__________________ Knee Replacement Date: ___________________________ Angioplasty Date:__________________ Rotator Cuff Repair Date: ___________________________ Pacemaker Date:__________________ Cataract Date:____________________________ Cardiac Valve surgery Date:__________________ Gallbladder surgery Date:____________________________ Hemorrhoidectomy Date:__________________ Hysterectomy Date:____________________________ Prostate Operation Date:__________________ Prostatectomy Date:____________________________ Hernia Repair Date:__________________ Appendectomy Date:____________________________ Tonsillectomy Date:__________________ Hip Replacement Date:____________________________ Mastectomy Date:__________________ Lumpectomy Date:____________________________ Other Operations:_____________________________________

Social History:

Tobacco Use: (Present &/or Past): Never Smoked

Quit smoking When? ________ How many years did you smoke? ______yr(s) How many packs? ______/day Currently Smoke Cigarettes Pipe Cigars How many packs? _____/day How many years?_________ Chewing Tobacco

Alcohol History: (Present &/or Past): Non Drinker

Beer number of bottles _________ per Day Week Month Wine number of glasses _________ per Day Week Month Liquor number of glasses _________ per Day Week Month

Are you: Employed/Self Employed Unemployed Retired Disabled

(Former) Occupation:______________________________________________________________________________ Name of Employer:___________________________________________ Work Phone: (______)__________________ Marital Status: Married Single Widowed Divorced Other

Lives Alone Lives with Family Lives in Nursing Home Winter Resident Year Round Resident

Children: Yes No


Health Maintenance:

Sigmoidoscopy / Colonoscopy: Yes No Date:_____________________________________________________ Findings:__________________________________________________ Last Mammogram: Date: ___________ Last Bone Density: Date: ___________ Last Pelvic Exam: Date _____________ Influenza (Flu) Shot: Date : __________ Pneumococcal Shot: Date : _________ Last Shingles Shot: Date : ___________ Last EGD: Date:___________________

Family Medical History: Indicate any family members with cancer, blood disease or other disease Age Disease If deceased, cause of death

Father: ____________ ________________________ ___________________________________________

Mother: ____________ ________________________ ___________________________________________

Siblings: ____________ ________________________ ___________________________________________ ____________ ________________________ ___________________________________________ ____________ ________________________ ___________________________________________ In your opinion, are there any diseases that run in your family? Yes No


Review of Symptoms: (Please check any current symptoms you have.)

General: Weight loss

How much__________________ Over what time period_________

Fevers Max temp__________ Chills Night sweats Fatigue EYES:

Wear Glasses/Contact Lenses Blurred Vision

Double Vision Ears, Nose, Throat:

Hard of hearing or deaf Ringing in Ears

Enlarged lymph nodes Chronic sinus Problems Sore throat Mouth pain/sores CHANGES/DIFFICULTY IN: Taste Smell Voice CARDIOVASCULAR:

Chest pain/Angina Pectoris Palpitations/heart murmur Irregular heart beat Pressure RESPIRATORY:

Chronic or Frequent Cough Bloody Sputum

Shortness of Breath


Difficult or painful swallowing Abdominal pain

Nausea Vomiting Heartburn Indigestion

Lump or sensation in throat Food sticking Bloating Belching Diarrhea Constipation Rectal bleeding Black or tarry stools Hidden blood in stool Excessive rectal gas/flatus Loss of stool/fecal accident Poor appetite Jaundice GENITOURINARY: Kidney Stones Pelvic Pain Incontinence

Burning or pain on urination Blood in Urine

Difficult urination Men: Prostate problems MUSCULOSKELATAL:

Joint Pain/Arthritis Muscle or joint weakness Back Pain

Bone Pain Muscle aches NEUROLOGICAL:

Numbness, tingling Arm or leg weakness Light-Headed, dizzy, fainting spells

Headache Tremors


Rashes or itching

Change in skin color or moles Varicose veins


Anxiety/Agitation Depression

Crying for no reason Insomnia


Drug Problem (Now/Past) HEMATOLOGIC:

Easy bruising

Gum or nose bleeding Blood transfusion in past Allergies/Immunology:

History of chronic infections History of allergies


Heat or cold intolerance Excessive Skin Dryness Excessive thirst or urination Weight problem

Hot flashes BREAST:

Rashes or itching

Change in skin color or moles Varicose veins

Skin Cancer Gynecology:

Age at start of menses_______ Last menstrual period________

Breast pain/lump Breast discharge or rash Vaginal discharge Menstrual irregularity or abnormal bleeding


MEDICATION LIST Date:___________________________ Name:_________________________________________ Date of Birth:_____________________________________

Your treatment can be affected by any medication that you take, and it is important that your physician has updated and correct information.

Drug Allergies: List all medication allergies

Medication:________________________________________ Reaction:_______________________________________ Medication:________________________________________ Reaction:_______________________________________ Medication:________________________________________ Reaction:_______________________________________ Medication:________________________________________ Reaction:_______________________________________

Are you allergic to:

Iodine Latex Shellfish CT Scan Dye / IV Contrast Eggs Peanuts

Other:____________________________________________________________________________________________ Type of Reaction:___________________________________________________________________________________

Pharmacy / address / phone #:_______________________________________________________________________

Listall medications (including non-prescription) that you are currently taking.


Primary Insurance Carrier:__________________________________________________________________________ Name of primary policy holder:______________________________________________________________________ Policy holder’s Date of Birth:____________________________ Policy holder’s SS#:__________________________ Policy holder’s employer:___________________________________________________________________________ Policy holder’s employer address: ___________________________________________________________________ Policy holder’s employer phone #: ___________________________________________________________________ Does plan have prescription coverage? Yes No

Secondary Insurance Carrier: _______________________________________________________________________ Name of secondary policy holder:____________________________________________________________________ Policy holder’s Date of Birth:____________________________ Policy holder’s SS#:__________________________ Policy holder’s employer:___________________________________________________________________________ Policy holder’s employer address: ___________________________________________________________________ Policy holder’s employer phone #: ___________________________________________________________________ Does plan have prescription coverage? Yes No

I certify that the information I have given today is to the best of my ability and as fully and accurately as possible. I will notify the doctor/staff to any changes or additions at subsequent visits.


I, ____________________________________________, request a copy of my complete medical

record from the office of:



Name and Address of Practitioner

To be sent to Florida Cancer Specialists:


Address, City State Zip Code


Fax/Telephone Number


I give permission to Fax my medical records to the above listed person, company or medical

facility. I understand that my records will be sent via telephone communication.


Provide office fax number

It is my understanding that by signing this authorization for release of my records, I am giving

permission for Florida Cancer Specialists to receive copies of any medical, psychiatric, AIDS, Aids

Related syndromes, HIV Testing, Alcohol and/or drug abuse related information for the above listed

person(s) or organization. I also understand that this authorization may be revoked at any time

except to the extent action has been taken prior to revocation. This consent will expire ninety (90)

days after the date below or sooner at my election.



Print Patient Name




Signature Patient, Parent, or Legal Guardian/Representative





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