Patient History Form Page 4
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4Gynecologic
Oncology
NAME: ________________________________________________________
FAMILY HISTORY: Please list any type of CANCER among the following:
Alive (A)
or
Deceased (D)
Father: ___________________________________________________________________________________
Mother: ___________________________________________________________________________________
Brother: ___________________________________________________________________________________
Sister: ____________________________________________________________________________________
Son: _____________________________________________________________________________________
Daughter: _________________________________________________________________________________
Husband: _________________________________________________________________________________
Other (aunts, uncles, cousins, grandparents): _____________________________________________________
__________________________________________________________________________________________
Any relatives with any of the following diseases? If so, who?
Diabetes __________ Tuberculosis __________
Stroke _________________ High Blood Pressure _________________ Heart Attack ____________________
SOCIAL HISTORY:
Do you smoke?
o Yes
o No
Packs per day: __________
Number of years: __________
When did you quit? ____________________
Any other form of tobacco? ___________________________
Do you use alcohol?
o Yes
o No
Amount per week: __________
Type: _____________________
Have you ever used drugs?
o Yes
o No
Past: __________
Present: __________
What type? ________________________________________________________________________________
Education:
o High school
o College
o Graduate school
Occupation: ________________________________________________________________________________
SYSTEM REVIEW: (Circle any of the following symptoms that you have now or have had in the past six months and describe if needed)
Any eye disease/injury
Back pain
Any ear disease/injury
Joint pain/stiffness
Chronic or frequent cough
Leg cramps or limp
Bloody sputum
Severe headaches
Chest pains
Nightmares or insomnia
Loss of consciousness/seizures
Fainting
Shortness of breath
Excessive worry/tension
Excessive nervousness
Depression
Rapid or irregular heartbeat
Serious marriage problems
Swelling of hands feet, ankles
Unusual hair growth/loss
Recent weight loss/gain
Hot flashes
How much? ____________
Abnormal thirst
Nausea or vomiting
Heartburn or indigestion
Difficulty swallowing
Salt cravings
Tremor/numbness hands/feet
Constipation
Diarrhea
Blood or mucous in stool
Excessive tiredness/weaknesses
Black or tarry stool
Breast discharge, change in size
Abdominal cramps or pains
Skin sores, rash or itching
Do you wear:
glasses
contacts
Lumps in breast or groin
dentures
hearing aid
PAGE 4 OF 4
NGPG FORM # 02422 (5/14/13)
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