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UCLA Thoracic Surgery
PO Box 957313, Room 64-128 CHS
10833 Le Conte Ave.
Los Angeles, CA 90095-
(310) 794-7333/Facsimile (310) 794-
MEDICAL HISTORY QUESTIONNAIRE
Robert B. Cameron, MD/Jay M. Lee, MD/ Raja S. Mahidhara, MD/ Mary Maish, MD, MPH
PERSONAL DATA:
REFERRING PHYSICIANS:
Please answer the following questions: Name:__________________________________ Today’s date:________________________________ Street:__________________________________ Age:_______Birthdate:________________________ City:____________________________________ Birthplace:__________________________________ State:______________Zip Code:_____________ E-mail address:______________________________ Home Telephone: (____)___________________ UCLA I.D. number:__________________________ Work Telephone: (____)____________________ Insurance source/policy no:____________________ Please check one of the following boxes and provide information on all physicians involved in your care: I was referred by one of my physician(s) below I was referred for a second opinion by my physician I referred myself with my physician’s knowledge I referred myself without my physician’s knowledge Name:____________________________________ Name:_____________________________________ Street:____________________________________ Street:_____________________________________ City:_____________________________________ City:_______________________________________ State:______________Zip Code:_______________ State:_______________Zip Code:________________ Telephone Number: (____)___________________ Telephone Number: (____)_____________________ Send reports to this physician_____________ Send reports to this physician Name:____________________________________ Name:_____________________________________ Street:____________________________________ Street:_____________________________________ City:_____________________________________ City:____________________________________ State:_____________Zip Code:________________ State:_______________Zip Code:________________ Telephone Number: (____)___________________ Telephone Number: (____)_____________________ Send reports to this physician Send reports to this physician
PRESENT ILLNESS:
SYMPTOMS: I have NEVER experienced any of the symptoms below
CURRENT MEDICATIONS: Currently, I am NOT taking ANY medications
MEDICATION/FOOD ALLERGIES: I have NO known food or drug allergies
Please briefly describe the date of onset of your illness, your symptoms and all tests/treatment you have received:
Please list ALL medications, doses, and frequencies (i.e., twice a day, every 8 hrs, etc.) below: Name Dose How often? Name Dose How often?
I sometimes take over the counter medications containing Aspirin (Anacin, etc.). I sometimes take over the counter medications containing Ibuprofen (Advil, Motrin, etc.). Please indicate if you have now or have ever experienced any of the following? (Check all that apply): New/changing cough Difficulty swallowing Chest pressure/tightness Phlegm/sputum production Food “sticking” Heart attack clear white green Pain with swallowing Fast/irregular heart beats brown bloody Regurgitation of food Palpitations Hoarseness/change in voice Nausea/vomiting Heart murmur Wheezing Vomiting blood Ankle swelling Asthma Ulcers/stomach trouble Difficulty breathing at night Emphysema Difficulty breathing lying flat Pneumonia Tuberculosis Loss of appetite Pleurisy Weight loss:_______lbs. Headaches Shortness of breath with exertion Weight gain:_______lbs. Weakness/fatigue Shortness of breath at rest Fever Pain/aches in joints Chest pain Night sweats Other:_________________ Please list ALL allergies and reactions to medications and food: Medication/Food Reaction: **_________________________________________ ______________________________________________
_________________________________________ ______________________________________________**
PREVIOUS SURGERY: I have NEVER had an operation of any kind
MEDICAL HISTORY: I have NEVER experienced any of the symptoms below
HOSPITALIZATIONS: I have NEVER been hospitalized for any reason
RADIATION THERAPY: I have NEVER received radiation therapy of any kind
CHEMOTHERAPY: I have NEVER received chemotherapy of any kind
Please list ALL operations you have had including: tonsils, appendix, hemorrhoids, hysterectomy, prostate surgery, etc: DATE OPERATION HOSPITAL SURGEON
Please indicate if you have now or have ever been told that you have any of the following? (Check all that apply): Abnormal EKG High blood pressure Abnormal Treadmill test Diabetes Angina/chest discomfort or pressure Stroke Heart attack Kidney Problem Heart condition Phlebitis Other:__________________________ Other:____________________________ Please list all hospitalizations excluding those for uncomplicated child birth: DATE ILLNESS HOSPITAL PHYSICIAN
Please list any chemotherapeutic agents you have received: START DATE STOP DATE AGENTS (IF KNOWN) HOSPITAL PHYSICIAN
Please list any prior radiation treatments you have received: START DATE STOP DATE BODY AREA TREATED HOSPITAL PHYSICIAN
FAMILY HISTORY: I have no knowledge of any of my living or deceased relatives
SOCIAL HISTORY:
Please record the state of health of your close blood relatives, i.e., mother, father, sisters, brothers, aunts, uncles, and grandparents: RELATIVE ALIVE? YES/NO HEALTH PROBLEMS/CAUSE OF DEATH AGE NOW/AT DEATH Father _________________ ________________________________________ ___________________ Mother _________________ ________________________________________ ___________________ Grandfather _________________ ________________________________________ ___________________ Grandfather _________________ ________________________________________ ___________________ Grandmother _________________ ________________________________________ ___________________ Grandmother _________________ ________________________________________ ___________________ Sister/Brother _________________ ________________________________________ ___________________ Sister/Brother _________________ ________________________________________ ___________________ Sister/Brother _________________ ________________________________________ ___________________ Sister/Brother _________________ ________________________________________ ___________________ Other:______ _________________ ________________________________________ ___________________ Other:______ _________________ ________________________________________ ___________________ Please indicate if ANY of your blood relatives has/had any of the following conditions (check all which apply): HEALTH PROBLEM RELATIVES AFFECTED: HEALTH PROBLEM: RELATIVES AFFECTED Alcoholism _____________________________ Hepatitis ___________________________ Anemia/unusual bleeding _____________________________ High Blood Pressure ___________________________ Arthritis _____________________________ High Cholesterol ___________________________ Asthma _____________________________ Kidney problems ___________________________ Cancer _____________________________ Liver problems ___________________________ Diabetes _____________________________ Obesity ___________________________ Glaucoma _____________________________ Strokes ___________________________ Gout _____________________________ Tuberculosis ___________________________ Heart trouble _____________________________ Other:______________ ___________________________ Please complete the following questions as COMPLETELY as possible: Marital Status: Single Married/Partnered Divorced Widowed Employment history: Currently employed Occupation:__________________Employer:_______________ Unemployed Retired (Date):_____________ Disabled (Date):___________ Previous Occupation:____________________________ What level of education have you attained? Grade school High School College Professional Have you traveled outside the U.S? No Yes If yes, Where?_____________When?____________ Have you ever served in the military? No Yes If yes, Which branch?________________________ With whom do you live____________________________ I live alone Do you have difficulty dressing yourself? No Yes Do you have difficulty carrying a 10 lb. bag or shopping? No Yes Have you ever fallen at home? No Yes If yes, When?___________________ Are you receiving any special help at home? No Yes If yes, Who helps you?________________ Do you follow any special diet? No Vegetarian Kosher Low fat Other:_____________
REVIEW OF SYSTEMS:
Please indicate if you have now or have ever experienced any of the following symptoms (Check all that apply): SYMPTOM WHEN SYMPTOM WHEN Infections Hemorrhoids................................ Now In Past Mumps................................... Now In Past Jaundice........................................ Now In Past German measles..................... Now In Past Hepatitis....................................... Now In Past Rheumatic fever..................... Now In Past Cirrhosis....................................... Now In Past Rubella................................... Now In Past Liver problems............................. Now In Past Mononucleosis....................... Now In Past Blood transfusions....................... Now In Past Polio....................................... Now In Past Gallbladder trouble...................... Now In Past Malaria................................... Now In Past Urine Typhoid fever......................... Now In Past Blood in urine.............................. Now In Past Shingles.................................. Now In Past Sugar in urine............................... Now In Past Gonorrhea.............................. Now In Past Albumin/protein in urine............. Now In Past Syphilis.................................. Now In Past Cloudy urine................................ Now In Past Skin Kidney stones............................... Now In Past Rashes.................................... Now In Past Prostate (men only) Tumors/unusual moles........... Now In Past Slow urine stream........................ Now In Past Psoriasis/eczema (circle one). Now In Past Urination at night: (# of times__) Now In Past Hair loss................................. Now In Past Circulation/Vascular Eye Leg pain with walking................. Now In Past Eye infection/pink eye........... Now In Past Poor circulation............................ Now In Past Blurred vision........................ Now In Past Varicose veins.............................. Now In Past Cataracts................................. Now In Past Muscles/Joints Glaucoma............................... Now In Past Back/bone pain............................. Now In Past Ears Arthritis/rheumatism.................... Now In Past Earache/discharge from ear(s) Now In Past Joint pains/deformity/redness...... Now In Past Ringing in the ears................. Now In Past Pain with weather changes........... Now In Past Spinning sensation/vertigo..... Now In Past Finger changing colors................. Now In Past Hearing loss........................... Now In Past Drainage from joints.................... Now In Past Nose and Mouth Locking joints.............................. Now In Past Sinus trouble.......................... Now In Past Muscle aches/stiffness.................. Now In Past Nosebleeds............................. Now In Past Motion limitation......................... Now In Past Bleeding gums....................... Now In Past Reproduction Sore tongue............................ Now In Past Pain with intercourse................... Now In Past Teeth trouble.......................... Now In Past Impotence/loss of libido............... Now In Past Lymph Neurological Lumps in groin(s).................. Now In Past Paralysis....................................... Now In Past Neck swelling......................... Now In Past Numbness/tingling of feet/hands. Now In Past Lumps in armpits................... Now In Past Difficulty walking........................ Now In Past Breasts Coordination problem/clumsiness Now In Past Lumps/pain in breast(s) ........ Now In Past Speech/memory problems............ Now In Past Nipple discharge.................... Now In Past Loss of bowel/bladder control..... Now In Past Gastrointestinal Dizziness/fainting spells.............. Now In Past Ulcers/stomach trouble.......... Now In Past Epilepsy/seizures.......................... Now In Past Black/tarry bowel movements Now In Past Psychological Bright red bowel movements. Now In Past Excessive worry/nervousness...... Now In Past Unusual constipation:............. Now In Past Depression/nervous disorder........ Now In Past Unusual diarrhea.................... Now In Past Personality disorder..................... Now In Past Change in stool size............... Now In Past Endocrine Change in stool color............. Now In Past Thyroid problems......................... Now In Past Change in stool frequency..... Now In Past Head/cold intolerance (circle one) Now In Past Indigestion/”gas”.................... Now In Past Unusual thirst/appetite................. Now In Past Abdominal pain...................... Now In Past Hand/foot swelling/enlargement.. Now In Past
TO BE FILLED OUT BY PHYSICIAN:
PHYSICAL EXAM:
Wt. _____ kg Ht. _____ BP _____ HR ______ RR _____ Temp ______ oC O 2 Sat (RA/ _______ L/min) _______ % General: appears younger older equal to the patient’s stated age appears in no mild moderate severe acute distress Eyes: pupils are equal and reactive anisocoric sluggish Other:______________________ sclera are anicteric mildly icteric moderately icteric unequally icteris > Ears: appears normal otorrhea bloody Nose: appears clear rhinorrhea hemorrhage masses Throat: appears clear bleeding gums poor dentition pharyngitis mass: location:_______ Neck: supple lymphadenopathy: left/ right; thyromegaly Other masses:__________ Back: CVA tenderness: left/ right; spinal tenderness: location:______________________ Lungs: clear rales: left/ right; rhonchi: left/ right; wheezing: left / right; dullness to percussion: left/ right; vocal fremitus: left/ right; egophony Heart: rate/rhythm: regular/ irregular; PMI in the 5th^ ICS murmur: grade: I/ II/ III/ IV, systolic/ diastolic/ other, radiation: to____; S1 S2; pericardial friction rub Abd: appears: soft scaphoid distended: mildly/ moderately/ severely; nontender tender: location_____________ hepatosplenomegaly masses: location______________ Vascular: carotid: Right: 1+ 2+ 3+ 4+ bruit; Left: 1+ 2+ 3+ 4+ bruit radial: Right: 1+ 2+ 3+ 4+ bruit; Left: 1+ 2+ 3+ 4+ bruit femoral: Right: 1+ 2+ 3+ 4+ bruit; Left: 1+ 2+ 3+ 4+ bruit pedal: Right: 1+ 2+ 3+ 4+ bruit; Left: 1+ 2+ 3+ 4+ bruit Ext: clubbing: 1+ 2+ 3+ 4+; cyanosis: 1+ 2+ 3+ 4+; LE edema: Right: 1+ 2+ 3+ 4+; Left: 1+ 2+ 3+ 4+ Rectal: deferred without masses mass: locations:____________ occult blood Prostate: deferred normal size enlarged without nodule(s) nodular Neuro: cranial nerves: intact deficiencies: _______motor: intact deficiencies:___________ sensory: intact deficiencies:______________proprioception: intact deficiencies:____ Psych: orientation: X4/ person/ place/ time/ situation; reacts: appropriate/ inappropriate Skin: normal suspicious nevi/lesions: location(s)______________ rashes: location(s)________ IMAGING EXAM: Chest CT: lung: RUL/ RML/ RLL/ LUL/ LLL; mediastinum esophagus chest wall other________; mass fluid infiltrate adenopathy PET Scan: Bone Scan: Head MRI: PFT: Other: PRIMARY EVALUATION: Note dictated by ______________ Note dictated at_______________ Dictation number _____________
