Palo Alto Medical Foundation Gynecologic Oncology Health History Form printable pdf download

Palo Alto Medical Foundation Gynecologic Oncology Health History Form

NAME: _____________________________

Date of Birth: ________________

Date of Visit: ________________

MEDICAL HISTORY

Who referred you for Consultation? __________________________ His / Her Specialty: _______________

Referring Dr.’s Address:

________________________________ Phone # (

) ___________________

________________________________

Are there any other physicians (e.g. Primary Care) with whom you would like your consultation discussed?

Dr.’s Name & Address:

_________________________________ Specialty: _______________________

_________________________________ Phone # (

) ___________________

For what reason were you referred?

Please Circle any symptoms and check any problems body system problems you have :

Excessive Weight gain or loss

Fever/Chills/Night sweats

Loss of appetite Fatigue/Malaise

Chest pain /Palpitations

Problems with urination

Nausea/Vomiting/heartburn/Change in bowel habit

Cough /Shortness of breath/Other Respiratory probs: ________ Allergy or Immune problems: ___________

Dizziness/Fainting/Headache/ Other Neurologic probs: ____________ Psychological problems: __________

Vaginal bleeding/discharge/Menstrual probs: ____________________________________________________

Problems with:

Skin

Eyes/Ears/Nose/Throat Blood/Lymph system Muscles Endocrine (glands)

(Explain:) _______________________________________________________________________________

Palo Alto Medical Foundation Gynecologic Oncology Health History Form