Patient History Form

Patient Name:

Birthdate:

Date:

Please specify here the type of Cancer that you have / had:

If other, please specify here:

Drug Allergies:

Current Medications:

Surgeries and Injuries:

Chief Complaint:

Family History

Please specify here the type of Cancer that you have / had:

If other, please specify here:

Social History

Occupation:

Retired?

Yes No

Do you...

Exercise Regularly

Use Alcohol

Use Tobacco

Use Drugs

Type of Exercise:

How often:

Type of alcohol (Beer / Wine / Liquor):

How often:

Type of Tobacco (Cigarettes / Cigars / Pipe / Snuff / Chew Tobacco):

Type of Drug (Marijuana / Heroin / Cocaine / LSD / Crack):

Is there anything that would prevent you from receiving blood transfusion?

Yes No

If necessary, do you consent for a BLOOD TRANSFUSION?

Yes No

Patient History

Do you consider yourself generally:

Healthy Not Healthy Other

If other, please specify:

Have you ever experienced or are you experiencing any of the following: (Please check all that apply)

Eyes

Blurred Vision

Painful Eyes

Irritation from light

Other

None

If other, please specify:

Cardiovascular (Heart)

Palpitations / Fluttering of Heart

Pain in Chest

Shortness of Breath while Exercising

Other

None

If other, please specify:

Respiratory (Lungs)

Wheezing

Shortness of Breath while Sitting

Cough

Other

None

If other, please specify:

Gastrointestinal (Stomach)

Constipation

Diarrhea

Pain

Reflux

Other

None

If other, please specify:

Genitourinary

Hesitation when Urinating

Urination at Night

Pain when Urinating

Other

None

If other, please specify:

Musculoskeletal

Soreness

Weakness

Cramping

Other

None

If other, please specify:

Integumentary (Skin)

Itchy Skin

Lesions on Skin

Bleeding

Dry Skin

Other

None

If other, please specify:

Neurological (Nerves)

Twitch

Ringing in Ears

Dizziness/Vertigo

Abnormal Movements

Other

None

If other, please specify:

Psychiatric

Mood Swings

Situational Stress

Change

Depression

Other

None

If other, please specify:

Endocrine

Hot Flashes

Hair Loss / Growth

Heat

Cold

Other

None

If other, please specify:

Hematologic / Lymph Nodes

Bleeding Easily

Night Sweat

Other

None

If other, please specify:

Allergic / Immunologic

Sneezing

Eye Irritation

Reactions

Other

None

If other, please specify:

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