Patient History Form Page 3
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4Gynecologic
Oncology
NAME: ________________________________________________________
MEDICAL PROBLEMS: (please circle)
Anemia
Heart attack
Chronic diarrhea
Convulsions
CHF/Angina
Hemorrhoids
Jaundice
Heart murmur
Colitis
Diabetes
High blood pressure
Irritable bowel
Stomach ulcer
Psychiatric disorder
Arthritis
Previous cancer
Bone disease
Migraines
Phlebitis
Back trouble
How often? ____________
Gallbladder
Hernia
Skin disease
Varicose veins
Bleeding problems
Name: ________________
Emphysema
Asthma/Hay fever
Kidney stone
Thyroid
Bronchitis
Glaucoma
Other: _____________________________________________________________________________________
Date of last mammogram: __________________
Date of last colonoscopy: __________________
Doctors who treat you for the above illnesses (cardiologist, lung doctor, etc.)
#1
#2
#3
Specialty:
_______________________
_______________________
_______________________
Name:
_______________________
_______________________
_______________________
Phone:
_______________________
_______________________
_______________________
Have you been hospitalized for any illnesses?
o Yes
o No
Diagnosis and year: __________________________________________________________________________
1. List all allergies to drugs: ___________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
2. Have you ever had a blood transfusion?
o Yes
o No
3. X-rays in the past year: ____________________________________________________________________
_______________________________________________________________________________________
MEDICATIONS: (please list)
Name of Medication
Dose of Medication
How Often?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
PAGE 3 OF 4
NGPG FORM # 02422 (5/14/13)
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Parent category: Medical