Personal Health History Template - Radiation Oncology
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1
2RADIATION ONCOLOGY CONSULTANTS
PERSONAL HEALTH HISTORY
Date____/____/____
NAME___________________________________________________________________________________
Last
First
Middle Initial
DOB _____/______/_________
Height _________
Sex M / F
Preferred Language _____________
ADDRESS __________________________________
CITY_______________
STATE ____ ZIP________
Primary (
) ______-_________
Okay to leave voicemail? Yes/No Alternative Number (
)_______-_________
RACE (circle one):
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Decline to answer
___________________________________________________________________
ETHNICITY (circle one):
Hispanic or Latino
Not Hispanic or Latino
Decline to answer
Please list your regular health care providers (Family Physicians, Internists, Gynecologists, Specialists, PAs, NPs,
others):
________________________________________________________________________________
PAST MEDICAL HISTORY :
Previous Operations/Procedures
Surgeon
Location
Month/Year of Procedure
_____________________________
______________________
__________________
________________________
_____________________________
______________________
__________________
________________________
_____________________________
______________________
__________________
________________________
_____________________________
______________________
__________________
________________________
_____________________________
______________________
__________________
________________________
Do you currently have, or have you previously had, any of the following? (Circle those that apply)
Arthritis
High Blood Pressure
Stroke
Cancer (before current problem)
Heart Disease
Pacemaker or Defibrillator (Please provide device card)
Diabetes
Heart Arrhythmia
Blood Clots
High Cholesterol
Epilepsy
Bleeding Tendency
Liver Disease
Colon Diseases
Indigestion/Acid Reflux/Stomach Ulcers
Asthma
COPD (chronic bronchitis or emphysema)
Kidney Disease
Prior Radiation Therapy
Depression
Other Psychiatric Disorders
Thyroid Disorders
Any other disorders? _____________________________________________________
Please list any ALLERGIES to medications and what reaction occurred: ______________________________________________
Present Medications
(prescription, non-prescription and supplements), list medications below or provide your list for photocopying:
Medication
Dose
Frequency/Time per Day
________________________
__________________
____________________
__________________
______________
_______________
__________________
______________
_______________
__________________
______________
_______________
__________________
______________
_______________
__________________
______________
_______________
***
Please let front desk know if you need additional space for medications***
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