Precision StemCell - StemCell Procedures

New Patient Questionaire

First Name: Last Name: D.O.B.: Age:

Address:

City: State: Zip Code:

Phone:

Cell: Fax:

Email:

Patient prefers to be called:

Language Preference:

English Other: If other explain:

Mode of Transportation: ambulatory wheel chair stretcher NONE

Name of physician involved in care	Would you like them to receive copies of our recommendation?
Primary Care / Internist:	Yes No
Surgeon:	Yes No
Medical Oncologist:	Yes No
Other (1):	Yes No
Other (2):	Yes No

Who will be with you during your procedure?

What is your understanding of why you need to be seen?

Describe briefly how your illness started, how it was diagnosed and what has happened up until now:

Reason for Consultation

What is your diagnosis?

At what hospital were you diagnosed?

When were you diagnosed?

Treatment you’ve received:	yes / no:	What Hospital:	Describe:
Surgery	Yes No
Radiation	Yes No
Drug Tx / Chemo	Yes No
Blood Transfusion	Yes No
Blood Support (Neupogen, etc.)	Yes No
Hormone Therapy	Yes No

Scans, X-Rays, or other tests related to your diagnosis

Test:	yes / no:	Performed Where?:	Date:
CT Scan	Yes No
MRI Scan	Yes No
Bone Scan	Yes No
Ultrasound	Yes No
Pet Scan	Yes No
Other	Yes No

Past Medical History

Have you had radiation before?

Yes No If yes, where?

Have you had any cancers? Yes No If yes, list below.

Date Diagnosed:	Type of Cancer:	Treatment Received:

Present Medical History

Do you have any ongoing of the following medical conditions:

Test:	yes / no:	If yes, describe:
High blood pressure	Yes No
Heart disease	Yes No
High cholesterol	Yes No
Heart attack	Yes No
Cardiac arrhythmia	Yes No
Blood clots (lung, leg, etc)	Yes No
Emphysema, asthma, COPD	Yes No
Kidney disease	Yes No
Stomach disease (ulcers, reflux)	Yes No
Bowel disease (inflammatory bowel disease, colitis, Crohn’s, etc)	Yes No
Diabetes (type I, type II)	Yes No
Thyroid problems	Yes No
Lupus	Yes No
Scleroderma	Yes No
ALS	Yes No
Other	Yes No
Other	Yes No

Past Surgical History

Have you had any other procedures or operations? Select one: Yes No If yes, please list below:

Date of surgery:	Type of surgery:	Hospital where performed:

Do you have an Internal Electronic Device, i.e. defibrillator, pacemaker? Yes No
If yes, please have your card ready at the time of consultation for the nurse and doctor.

Allergies (medication, food, latex, etc)? Yes No If yes, please describe below:

	Allergy to:	Describe reaction:

List all prescribed medication that you are currently taking

Drug:	Dose:	How Often:	Prescribed by:	Why:

List any over-the-counter medications you are currently taking (Tylenol, Advil, Antacids, Vitamins, etc)

Drug:	Dose:	How Often:	Prescribed by:	Why:

Social History

Marital status: (select one)

Single Married Divorced Widowed

Do you drink alcohol?

Number of drinks per week:

If you used to drink, when did you stop?

Do you smoke?

Yes No If yes, packs per day for years

What type of work do / did you do?

Are you retired?

Yes No If yes, when?

Do you live alone?

Yes No If no, with whom do you live?

Do you have children?

Yes No If yes, list ages:

Do you use recreational drugs? (Marijuana, cocaine, etc.)

Yes No If Yes, which drugs?

Family History

Do / did any family members suffer from cancer or blood disease? Yes No

If yes, please describe below:

Family member	Type of cancer / blood disease	Age at diagnosis

Women:

Do you have regular mammograms?

Yes No Last Exam:

Do you have regular PAP test?

Yes No Last Exam:

Do you have regular breast exams?

Yes No Last Exam:

Do you examine your own breasts?

Yes No Last Exam:

Female History (N/A to Male Patients)

Date of last menstrual period:

Age that you started menstruating:

Age at menopause:

Have you had a hysterectomy?

Yes No If yes, were your ovaries removed?

Do / did you use oral contraceptives?

Yes No If yes, how many years?

Do / did you use hormone replacement therapy?

Yes No If yes, how many years?

Number of pregnancies:

Number of live births:

Men:

Do you have regular prostate exams?

Yes No Last Exam:

Do you have regular PSA tests?

Yes No Last Exam:

Do you examine your own testicles?

Yes No Last Exam:

Health Maintenance:

Have you had a flu vaccine?

Yes No When?

Have you had a pneumonia vaccination?

Yes No When?

Have you had a sigmoidoscopy / colonoscopy?

Yes No When?

Has your doctor checked your stool for blood?

Yes No When?

Advance Directives

Do you have a living will?

Yes No

Do you have a Durable Power of Attorney for Health Care?

Yes No

If yes to either of the above, will you have the documents with you?

Yes No

If unavailable:

Name of Agent:

Phone number:

Essence of Advance Directive in patient / family words:

If no, would you like assistance obtaining this information? Yes No

Contact Information

Name of closest relative:

Address:

Home phone:

Work phone: Cell phone:

Emergency contact person:

Relationship:

Address:

Home phone:

Work phone: Cell phone:

Review of Systems (Select appropriate response)

General:

Fever, fatigue, night sweats, chills, hot flashes

Yes No If yes, explain:

Difficulty sleeping, changes in appetite

Yes No If yes, explain:

Weight loss / gain?

Yes No If yes, how many pounds in which direction?

Describe your activity level:

Skin:

Rash, moles or changes in
moles, sores, lumps, dryness, itching?

Yes No If yes, explain:

Healing incision, vascular access (port a cath, pic line)

Yes No If yes, explain:

If yes, last date flushed:

Eyes, Ears, Nose, Throat:

Wear hearing aid(s)

Dentures

Blurred vision, double vision, red / water eyes, blind

Yes No If yes, explain:

Glaucoma

Yes No If yes, explain:

Corrected vision (glasses / contacts)

Yes No If yes, explain:

Cataracts / Surgery

Yes No If yes, explain:

Macular degeneration

Yes No If yes, explain:

Hard of hearing, ringing in the ears, ear pain

Yes No If yes, explain:

Frequent sinus infections, sore throat, hoarseness, mouth pain

Yes No If yes, explain:

Change in taste, smell, difficulty swallowing

Yes No If yes, explain:

Respiratory:

Shortness of breath

Cold, sore throat or fever in the last 2 weeks

Yes No If yes, explain:

COPD, bronchitis, asthma, emphysema

Yes No If yes, explain:

Hospitalized / in ER in the last 6 weeks (respiratory related)

Yes No If yes, explain:

Pneumonia, hemoptysis (cough up blood)

Yes No If yes, explain:

Able to walk two flights of stairs

Yes No If NO, explain:

Sleep disorders, sleep apnea

Yes No If yes, explain:

Pulmonary embolism

Yes No If yes, explain:

Home oxygen?

Yes No If yes, how many liters / min:

Cardiovascular:

Rheumatic heart disease

Yes No If yes, explain:

Heart murmur, valvular disease

Yes No If yes, explain:

Angina, chest pain

Yes No If yes, explain:

MI (heart attack) Angioplasty, bypass, graft

Yes No If yes, explain:

Arrhythmia, palpitations, atrial fib, SVT

Yes No If yes, explain:

High blood pressure

Yes No If yes, explain:

Pacemaker, defibrillator

Yes No If yes, explain:

Blood clots in legs

Yes No If yes, explain:

PVD (peripheral vascular disease)

Yes No If yes, explain:

Congestive heart failure, dizziness, fainting

Yes No If yes, explain:

Abdominal aortic aneurysm

Yes No If yes, explain:

Genitourinary:

Frequent urinary tract infections

Yes No If yes, explain:

Blood in urine, kidney stones

Yes No If yes, explain:

Pain, frequency, difficulty with flow, incontinence

Yes No If yes, explain:

Prostate disease

Yes No If yes, explain:

Renal insufficiency

Yes No If yes, explain:

Chronic renal failure, new onset renal failure

Yes No If yes, explain:

Failure, dialysis (peritoneal / hemo)

Yes No If yes, explain:

Gastrointestinal:

GI bleeding, stomach ulcer,
reflux (GERD), heartburn, hiatal hernia

Yes No If yes, explain:

Chronic / acute hepatitis B / C / D / G

Yes No If yes, explain:

Cirrhosis, jaundice

Yes No If yes, explain:

Constipation, diarrhea, blood in stool

Yes No If yes, explain:

Irritable bowel syndrome, colitis, Crohns disease

Yes No If yes, explain:

Difficulty swallowing/chewing

Yes No If yes, explain:

Muscoskeletal:

Weakness in extremities

Yes No If yes, where:

Bone pain (not arthritis)

Yes No If yes, where:

Limited movement

Yes No If yes, explain:

Prosthesis, metal in joints, artificial joints

Yes No If yes, explain:

Joint pain, joint swelling, fibromyalgia, arthritis

Yes No If yes, explain:

Chronic back pain, back injury, neck injury

Yes No If yes, explain:

Difficulty opening your mouth

Yes No If yes, explain:

Spinal pain, spinal stenosis, cervical fusion

Yes No If yes, explain:

Pain:

Chronic

New

Neurological:

Stroke, TIA, Parkinson’s, polio

Yes No If yes, explain:

Paralysis, tremors, weakness

Yes No If yes, explain:

Multiple Sclerosis

Yes No If yes, explain:

Epilepsy, seizures, convulsions

Yes No If yes, explain:

Brain aneurysm, head injury

Yes No If yes, explain:

Neuro implants: BP shunt, epidural device

Yes No If yes, explain:

Have you recently experienced:

Loss of speech, memory loss, forgetfulness, slurred speech, speech impairment,
changes in vision, numbness, tingling, headache?

Yes No If yes, explain:

Endocrine / Metabolic:

Diabetes

Yes No If yes, select: Type I Type II NONE

Thyroid disease

Yes No If yes, select: Hypo Hyper NONE

Insulin pump

Yes No If yes, explain:

Hypoglycemia

Yes No If yes, explain:

Hematological / Lymphatic:

Blood transfusion, anemia

Yes No If yes, explain:

Prolonged bleeding, excessive bruising

Yes No If yes, explain:

Enlarged lymphnodes

Yes No If yes, explain:

Immunologic:

Lupus

Yes No If yes, explain:

Chronic fatigue syndrome

Yes No If yes, explain:

AIDS / HIV

Yes No If yes, explain:

Immunosuppression

Yes No If yes, explain:

Other Explain:

Infectious Disease:

Recent exposure to an infectious disease

Yes No If yes, explain:

Tuberculosis

Yes No If yes, explain:

In isolation

Yes No If yes: Type:

Date:

Psychosocial / Behavioral:

Currently experiencing stress in your life?

Yes No (1=mild, 10=high):

Currently have concerns regarding
sleep patterns, appetite, eating habits, energy level

Yes No If yes, explain:

Panic disorder, depression, bipolar, anxiety

Yes No If yes, explain:

Religious, spiritual, or cultural needs

Yes No If yes, explain:

Obsessive / compulsive, schizophrenia

Yes No If yes, explain:

Other Explain:

Nutritional:

Diet (General, diabetic, cardiac, etc.)

Yes No If yes, explain:

Food Allergies

Yes No If yes, explain:

On a supplement

Yes No If yes, explain:

Recent surgery (less than 2 months)

Yes No If yes, explain:

Poor oral intake (less than 50% for 3 days)

Yes No If yes, explain:

Difficulty chewing / swallowing

Yes No If yes, explain:

Please type the exact letters you see in the box:
(if you can not recognize the characters hit F5 to refresh the page)