Cape Fear Valley Cancer Center Ambulatory Summary List



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Cape Fear Valley Cancer Center Ambulatory Summary List


This form is to help your doctor give you better health care. It is completely confidential, and will be part of your medical record.

NAME:

Date of Birth:

Home Phone ( ) Cell Phone ( ) Work Phone ( )

Occupation:

Retired? (circle one) Yes / No

Primary Care Doctor:

Doctor who referred you to us:



Other Doctors to receive Oncology Treatment Notes if any:






Pharmacy Name:

Pharmacy Address:



Pharmacy Phone ( )

Emergency Contact Name: Home Phone ( )

Relationship to you: Cell Phone ( ) Work Phone ( )

Marital Status: (circle one) Married / Single / Widowed / Separated / Divorced

I live with: (circle one) Spouse / Significant Other / Alone / Family / Supervised Living / Other

Medical History (circle all that apply)


No other medical problems

GI Bleeding

Fibromyalgia

Chicken Pox / Shingles

Stomach Problems

Arthritis

Measles / Mumps / Rubella

Ulcerative Colitis/Crohn’s

Gout

Heart Attack

Gall Bladder Problems

Thyroid Problems

High Blood Pressure

Jaundice / Hepatitis / Liver Problem

Diabetes / Sugar Problems

Heart Murmur

Kidney / Bladder Problems

Eczema / Psoriasis

High Cholesterol

Sexual Problems

Prostate Problems

Congestive Heart Failure

HIV / Aids

Breast Problems

Pacemaker / Defibrillator

Seizure Disorder / Convulsions

Anemia / Blood Problems

Stroke

Nervous Disorder

Blood Transfusions

Asthma

Depression

Previous Cancer

Emphysema / COPD

Mental Illness

Nonmedical Radiation Exposure

Pneumonia

Dementia

Other: _______________

Glaucoma

Headaches

Other: _______________

Cataracts

Chronic Pain

Other: _______________

For Women Only


Age at onset of menstrual period: Date of last menstrual period:

Is there a possibility that you are currently pregnant? Yes No NA

Ever taken birth control pills? Yes / No How long? _______ years

Number of pregnancies: Number of live births:

Ever taken hormone replacement therapy? Yes / No How long? ________years

Prior Surgeries or Hospitalizations


Month / Year

Operation or Hospitalization
























Prior Cancer Treatments


Month / Year

Type of Chemotherapy or Radiation Site


















Allergies


List all allergies: Food / Drug / Latex

Reaction and Severity


















Medications


List all medications you currently take, or provide list to nurse:

Medication

Dose

Times / day

Medication

Dose

Times / day


























































































Vitamins, Minerals, Herbs, Supplements


Vitamin/mineral/herb/supplement

Dose

Times per day



























Habits


Do you use: (circle all that apply) Cigarettes / Cigars / Chewing Tobacco / Snuff

Number of years: _______ Quit date: _______ If cigarettes, packs per day: _______

Do you use alcohol: (circle one) Yes / No

Number of Years: _______ Quit Date: _______ Drinks per Week: _______

Have you used recreational drugs: (circle one) Yes / No

Please list family members with any type of cancer or blood disorder:




Review of Symptoms (circle all that apply)


Constitutional

Musculoskeletal

Fevers

Tire easily

Difficulty walking

Painful legs / feet

Night sweats




Difficulty standing

Back pain / ache

Recent weight loss

# lbs _______

time frame ______


Recent weight gain

# lbs _______



time frame ______

Difficulty lifting

Neck pain / stiffness

Joint aches / stiffness










Cardiology

Respiratory

Chest pain

Feeling you might pass out

Shortness of breath

Cough producing blood

Ankle swelling

Rapid/irregular heart beat

Dry cough

Cough producing sputum

Gastrointestinal

Genitourinary

Loss of appetite

Black/tarry stools

Painful urination

Unable to control urine

Heartburn / indigestion

Bloody stools

Difficulty emptying bladder

Having to get up at night to urinate

Stomach pain/discomfort

Diarrhea

Gas or cramps

Constipation

Frequent urination

Bladder infections

Changes in taste

Nausea

Blood in urine

Vaginal itching / discharge

Trouble swallowing

Vomiting




Sexual problems

Eyes, Ears, Nose, Throat, Mouth

Neurologic

Recent vision changes

Hearing loss

Difficulty concentrating

Dizziness

Tooth pain

Hearing aid(s)

Numbness in hands / feet

Memory changes

Other dental problems

Ringing in ears

Headaches




Hoarseness

Ear pain







Sore throat

Nosebleeds






Psychosocial Distress Screening


I am currently experiencing (circle number corresponding to your distress level):

No

Distress





























Extreme

Distress


0

1

2

3

4

5

6

7

8

9

10

Please circle any of the items below that are causing distress:


Practical Problems

Family Problems

Emotional Problems

Spiritual / Religious

Housing

Dealing with partner

Worry

Any concerns

Money / Financial

Dealing with children

Fears

Insurance

Dealing with other

Sadness

Work




Depression

School




Nervousness

Transportation




Loneliness

Child Care






Other problems, things you would like us to know:

Patient Name: ________________________
Date of Birth: ________________________
Medical Record Number: _______________ For Office / Nursing Use Only
Physician: HB SS IP TW SGD KB SM KM KF Consult Type: NEW R/C
Cancer Diagnosis: _______________________________
Ht: ________ Wt: __________ T: ________ P:_______ R: ________ B/P: ________
Patient Learns Best By: Reading Listening Demonstration
Pain: Y N Location: _______________________________
Current Level: ________ Worst(24 hrs): ________ Least(24 hrs):________
Constant / Intermittent / Brief
Describe Pain: _________________________________________________________________
What makes better: ____________________________ makes worse: _____________________

Signature / Title:

________________________
Date: ______________

Time:_______________


Rev.10/12

Revised: 8/13 mmc


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