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UCSF Cancer Center New Patient Questionnaire Patient Name Date of Birth Referring Physician Physician Name Physician Specialty Address City State Phone Fax Your Other Physicians Please provide the contact information for your other physicians so that we can send them updates on your care here at the Cancer Center. ZIP Primary Care Physician Physician Name Physician Specialty Address City State Phone Fax ZIP Surgeon Physician Name Physician Specialty Address City State Phone Fax ZIP Medical Oncologist Physician Name Physician Specialty Address City State Phone Fax ZIP Other Physician Name Physician Specialty Address City State Phone Fax ZIP

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Page 1: Patient Name Date of Birth Your Other Physicians · Patient Name Date of Birth. Referring Physician. Physician Name. Physician Specialty Address. City State. Phone Fax. Your Other

UCSF Cancer Center New Patient Questionnaire

Patient Name

Date of Birth

Referring Physician

Physician NamePhysician SpecialtyAddressCity StatePhone Fax

Your Other PhysiciansPlease provide the contact information for your other physicians so that we can send them updates on your care here at the Cancer Center.

ZIP

Primary Care PhysicianPhysician NamePhysician SpecialtyAddressCity StatePhone Fax

ZIP

SurgeonPhysician NamePhysician SpecialtyAddressCity StatePhone Fax

ZIP

Medical OncologistPhysician NamePhysician SpecialtyAddressCity StatePhone Fax

ZIP

OtherPhysician NamePhysician SpecialtyAddressCity StatePhone Fax

ZIP

Page 2: Patient Name Date of Birth Your Other Physicians · Patient Name Date of Birth. Referring Physician. Physician Name. Physician Specialty Address. City State. Phone Fax. Your Other

UCSF Cancer Center New Patient Questionnaire

Patient Name

Date of Birth

anaphylaxis/shock short-of-breath

nausea/vomitting itching rash other _____________

eggs

latex

iodine/shellfish

bee stings

intravenous contrast (used in CT scans)

Have you ever had an allergic reaction? Please check all that apply.

Allergies

Page 3: Patient Name Date of Birth Your Other Physicians · Patient Name Date of Birth. Referring Physician. Physician Name. Physician Specialty Address. City State. Phone Fax. Your Other

UCSF Cancer Center New Patient Questionnaire

Patient Name

Date of Birth

Name of Medication or Supplement

Form (tablet, chewable tablet, elixir, etc)

Dosage Strength per Tablet or Liquid Concentration

Amount of Medication per Dose

Frequency, or as needed

Medications and SupplementsDo you take any medications or supplements? Include all prescription, over-the-counter, and topical medications. Include all supplements, vitamins, and herbs.

Your PharmacyPharmacy NameAddressCity StatePhone Fax

ZIP

Page 4: Patient Name Date of Birth Your Other Physicians · Patient Name Date of Birth. Referring Physician. Physician Name. Physician Specialty Address. City State. Phone Fax. Your Other

UCSF Cancer Center New Patient Questionnaire

Patient Name

Date of Birth

Medical HistoryPlease check all that apply.

Arrhythmias or Coronary Artery Disease (CAD)

Anemia (low red blood cell count)

Angina (heart pain from poor blood flow)

Anxiety or Panic Attacks

Arthritis

Asbestos Exposure

Asthma/Bronchitis

Atrial Fibrillation (A Fib or Heart Flutter)

Autoimmune Disease

Bleeding Disorder (Hemophilia)

Blood Disorder

Blood Transfusion (in the past)

Cancer

Chest Pain

Chronic Bronchitis

Chronic Obstructive Pulmonary Disease (COPD)

Cirrhosis (Liver Failure)

Clotting Disorder

Congestive Heart Failure (CHF)

Deep Vain Thrombosis (DVT)

Depression

Diabetes Mellitus - IDDM (taking insulin)

Diabetes Mellitus - NDDM (not taking insulin)

Easy Bruising

Emphysema

Gastroesophageal Reflux Disease (GERD), Acid Reflux, or Heartburn

GI Bleed

Glaucoma

Heart Murmur

Heart Valve Problem

Hepatitis, Chronic

Hiatal Hernia (upper stomach)

HIV/AIDS

Hypertension (High Blood Pressure)

Immune Disorder

Intestinal Disease or Problem

Liver Disease

Lung Disease

Melanoma

Migraine Headaches

Morbid Obesity BMI>=38

Myocardial Infarction (MI or Heart Attack)

Nerve or Muscle Disease

Osteoporosis (loss of bone strength)

Pancreatitis, Chronic

Palpitations, Heart or Fast or Irregular Heartbeats

Peripheral Vascular Disease (PVD)

Psychiatric Treatment (mental health medication)

Pulmonary Embolism (blood clot in lungs)

Renal Disease, Failure, or Insufficiency (CRI)

Seizures or Epilepsy

Sexually Transmitted Infection (STI) or Disease (STD)

Sinus Disorder

Skin Disease

Stomach Ulcer

Stroke, Mini Stroke, or Transient Ischemic Attack (TIA)

Substance Abuse (see later section)

Thyroid Disease

Tuberculosis (TB)

Ulcer, not stomach (open sore that doesn't heal)

Other

Other

Page 5: Patient Name Date of Birth Your Other Physicians · Patient Name Date of Birth. Referring Physician. Physician Name. Physician Specialty Address. City State. Phone Fax. Your Other

UCSF Cancer Center New Patient Questionnaire

Patient Name

Date of Birth

Appendix

Brain

Breast

Caesarean Section (C-Section)

Colon

Coronary Artery Bypass (CABG)

Gallbladder

Heart Valve Replacement (Pacemaker)

Hernia

Hysterectomy

Joint Replacement

Liver

Ovary

Pancreas

Prostate

Spine

Tonsillectomy

Tubal Ligation

Vasectomy

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Date & Comments

Surgical HistoryPlease check all that apply.

Other Date & Comments

Other Date & Comments

Page 6: Patient Name Date of Birth Your Other Physicians · Patient Name Date of Birth. Referring Physician. Physician Name. Physician Specialty Address. City State. Phone Fax. Your Other

UCSF Cancer Center New Patient Questionnaire

Patient Name

Date of Birth

Family History of Cancer

Type of Cancer

Other Medical Conditions

Age at Diagnosis Current Age

If Deceased, Age at Death

Mother

Father

Sister

Sister

Brother

Brother

Daughter

Son

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Other

Maternal Aunt

Maternal Uncle

Paternal Aunt

Paternal Uncle

Were you adopted? Yes No

Please complete the following table for your biological relatives.

Page 7: Patient Name Date of Birth Your Other Physicians · Patient Name Date of Birth. Referring Physician. Physician Name. Physician Specialty Address. City State. Phone Fax. Your Other

UCSF Cancer Center New Patient Questionnaire

Patient Name

Date of BirthLifestyleDo you drink alcohol?If Yes, what is your average number of: Glasses of Wine per Week

Cans of Beer per WeekShots of Liquor per Week

In regards to smoking, please choose one:

How many years have/did you smoke? At what age did you start smoking?How many packs of cigarettes per day do you/did you smoke?If you quit, when did you quit? (approximate month/day/year)

Do you use smokeless tobacco?

Please check any drugs that you use for recreational use.

Amphetamines

Amyl Nitrate

Anabolic Steroids

Barbiturates

Benzodiazepines

"Crack" Cocaine

Cocaine

Codeine

Fentanyl

GHB

Heroin

Hydrocodone

Hydromorphone

Ketamine

LSD

Marijuana

MDMA Ecstasy

Methamphetamine

Methaqualone

Methylphenidate

Morphine

Nitrous Oxide

Opium

Oxycontin

PCP

Psilocybin

Solvent Inhalants

Other

Other

Yes No

Current Smoker

Never Smoked

Passive Smoker (2nd hand)

Former Smoker

Never UsedFormer UserCurrent User

Page 8: Patient Name Date of Birth Your Other Physicians · Patient Name Date of Birth. Referring Physician. Physician Name. Physician Specialty Address. City State. Phone Fax. Your Other

UCSF Cancer Center New Patient Questionnaire

Patient Name

Date of Birth

Please check all illnesses, problems, and symptoms you have had in the last month.

CONSTITUTIONAL SYMPTOMSActivity changeAppetite changeChillsDiaphoresis (excessive sweating)Fatigue (or malaise)FeverUnexpected weight changeWeakness

EARS/NOSE/MOUTH/THROATNeck painNeck stiffnessHearing lossEar painTinnitus (ringing in the ears)NosebleedsCongestionRhinorrhea (runny nose)Postnasal dripSneezingSinus pressureDental problemTrouble swallowingVoice change

EYESEye dischargeEye painEye rednessPhotophobia (irritation with lights)Visual disturbance (blurred or double vision)

RESPIRATORYApneaChest tightnessChokingCoughShortness of breathStridor (groaning sound while breathing)

CARDIOVASCULARLeg SwellingPalpitations (fluttering in chest)

GASTROINTESTINALAbdominal distention (swelling)Abdominal pain Anal bleedingBlood in stoolConstipationDiarrheaNauseaRectal PainVomiting

URINARYDifficulty urinatingDysuria (burning when you urinate)Enuresis (cannot control urinating)Flank pain (between ribs and hip)Hematuria (blood in urine)Menstrual problem (Females)Pelvic pain (Females)Penile discharge (Males)Penile pain (Males)Penile swelling (Males)Scrotal swelling (Males)Testicular pain (Males)Urgency (need to urinate quickly,

can barely hold it)Urine decreasedVaginal bleeding (Females)

MUSCULOSKELETALBack painGait problemsJoint swellingMyalgias (crampy muscle pain)

SKINPallorWound

NEUROLOGICALFacial asymmetryHeadachesLight-headednessSeizuresSpeech difficultySyncope (fainting)TremorsWeakness

HEMATOLOGIC/LYMPHATICAdenopathy (swelling of lymph nodes)Bleeding or bruising tendency

PSYCHOLOGICALBehavior problemConfusionDecreased concentrationDysphoric (depressed) moodHallucinationsNervous/anxiousSelf-injurySleep disturbance

Review of Symptoms


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