NEW YORK RADIATION ONCOLOGY ASSOCIATES, P.C.

9202 Liberty Avenue, Ozone Park, NY 11417-1526 ● Tel: 718.835.9729 ● Fax: 718.925.9817

Date: _______________________

PATIENT MEDICAL HISTORY FORM

(The requested information is very vital to your health. Please take time to fully and completely fill out this form. This is pertinent information and we expect you to be diligent in doing so.)

NAME: _________________________________________ DOB: _____________________ AGE:__________________

_______ _______

HEIGHT: ___________________ WEIGHT: ___________________ GENDER: M	F

REASON FOR VISIT: _________________________________________________________________________________

_________________________________________________________________________________________________

PRIMARY CARE PHYSICIAN: __________________________ REFFERING PHYSICIAN _____________________________

Please indicate the Medical/Clinical Procedures you have had:

TYPE OF SURGERY	DATE	FACILITY/HOSPITAL
1.
2.
3.
X-RAYS	DATE	FACILITY/HOSPITAL
1.MRI
2. CT-SCAN
3. PET-SCAN
4. ULTRASOUND
5. MAMMOGRAM
OTHER HISTORY
DATE TYPE OF OPERATION FACILITY/HOSPITAL
1.
2.
3.
CURRENT MEDICATIONS
MEDICATIONS	FREQUENCY
1.
2.
3.
4.
ALLERGIES TO MEDICATIONS
1.
SOCIAL HISTORY

_______ _______

Do you smoke? Y	N	how many packs/day? _______ Age started? _____

_______ _______

Are/Were you exposed to second hand smoke?	Y	N

_______

_______ Alcohol Use?	Y	N

What is your occupation? ____________________________________

FAMILY MEDICAL HISTORY

_______ _______

Cancer Y	N	Type of Cancer	Relationship

1._______________________	___	_________________________

2.________________________	_________________________

3.________________________	_________________________

GYNECOLOGICAL HISTORY

MENARCHE	Age ___________

________ ________

PERIODS	Regular	Irregular

MENOPAUSE	Age ___________

# OF PREGNANCIES	_______________

# OF FULL-TERM DELIVERIES	_______________

________ ________	CAESAREAN Y	N

________ ________

Is there a chance you may be pregnant?	Y	N

REVIEW OF SYSTEMS

Have you been diagnosed with or are currently having problems with any of the following:

(please encircle to indicate your answers).

SKIN	RESPIRATORY	GASTROINTESTINAL
Psoriasis	Y	N	Shortness of Breath	Y	N	Heartburns	Y	N
Eczema	Y	N	Wheezing	Y	N	Ulcers	Y	N
Jaundice	Y	N	Emphysema/COPD	Y	N	Abdominal Pain	Y	N
Pulmonary Embolism	Y	N	Acid Reflux Disease	Y	N
CARDIOVASCULAR	Asthma	Y	N	Pancreatitis	Y	N
Chest Pain	Y	N	Chest Tightness	Y	N	Diverticulitis	Y	N
Congest. Heart Failure	Y	N	Lung Cancer	Y	N	Cirrhosis	Y	N
High Blood Pressure	Y	N	Recurrent Bronchitis	Y	N	Crohn’s/Colitis	Y	N
Heart Valve Problems	Y	N	Bloody Cough	Y	N	Irritable Bowel Synd.	Y	N
Heart Murmur	Y	N	Recurrent Cough	Y	N
Heart Attack	Y	N	Productive Cough	Y	N	INFECTIOUS DISEASE
Pacemaker	Y	N	Hepatitis (A,B or C)	Y	N
Palpitations	Y	N	KIDNEY	Chronic Fatigue Synd.	Y	N
Rheumatic Fever	Y	N	Kidney Failure	Y	N	Chronic Epstein-Barr	Y	N
Irregular Heart Beat	Y	N	Recur Kidney Infection	Y	N	Tuberculosis	Y	N
Urinary Retention	Y	N	AIDS/HIV	Y	N
ENDOCRINE
Thyroid Problems	Y	N	NEUROLOGIC	MUSCULOSKELETAL
Chronic Fatigue	Y	N	Seizure	Y	N	Chronic Back Problems	Y	N
High Blood Sugar	Y	N	Multiple Sclerosis	Y	N	TMJ Syndrome	Y	N
Excessive Thirst	Y	N	Loss of Strength	Y	N	Chronic Neck problems	Y	N
Diabetes	Y	N	Stroke/TLA	Y	N	Arthritis	Y	N
Lupus	Y	N	Parkinson’s	Y	N	Fibromyalgia	Y	N
Migraine Headaches	Y	N	MS or MD	Y	N
PSYCHOLOGIC	Numbness	Y	N
Depression	Y	N	HEMATOLOGIC
Bipolar Disorder	Y	N	IMMUNE SYSTEM	Anemia	Y	N
Anxiety/Nervousness	Y	N	Lupus	Y	N	Immune Deficiency	Y	N
Paranoia	Y	N	Autoimmune Disease	Y	N	Leukemia	Y	N
Schizoprenia	Y	N	Immune Deficiency	Y	N	Clotting Problem	Y	N