New Patient Form Step 1 of 7 14% Date MM slash DD slash YYYY Name First Last Sex Female Male Date of Birth MM slash DD slash YYYY AgeMarital Status Single Married/Partnered Divorced Separated Widowed How long?Ethnicity White/Caucasian Black/African American Native Hawaiian or other Pacific Islander Ashkenazi Jewish Hertitage Asian American indian od Alaska Native Hispanic/Latina Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry Home PhoneCell PhoneEmail Preferred method of communication Home Cell Email OccupationIf retired or disabled since when? Referring Physician First Last Primary Care Physician First Last We would like to know how you selected the Margie Petersen Breast Center at Providence Saint John’s Health Center: My physician recommended I come I asked my physician to refer me I referred myself A friend or relative referred me History of your present health problem or illness for which you are seeking care at the Margie Petersen Breast Center at Providence Saint John’s Health Center:Please describe briefly, in your own words, the date of onset of your current problem or illness, any symptoms you have experienced, and the dates of any tests and/or treatment(s), with the names and addresses of physicians whom you have consulted. Do you have any symptoms or concerns related to the following categories? Ears, Eyes, Nose Please describe symptom(s) and when it occurred. Throat Please describe symptom(s) and when it occurred. Lungs Please describe symptom(s) and when it occurred. Heart/Cardiac Please describe symptom(s) and when it occurred. Abdomen Please describe symptom(s) and when it occurred. Musculoskeletal Please describe symptom(s) and when it occurred. Neurologic/Fatigue/Forgetfulness Please describe symptom(s) and when it occurred. Skin Please describe symptom(s) and when it occurred. Endocrine/Thyroid Please describe symptom(s) and when it occurred. Hematology/Bleeding Please describe symptom(s) and when it occurred. Gynecological/Urology Please describe symptom(s) and when it occurred. Psychologic Please describe symptom(s) and when it occurred. Breast Please describe symptom(s) and when it occurred. Other Please describe symptom(s) and when it occurred.Are you experiencing pain at this time? Yes No Please rate on a scale of 0-10, your level of pain:(0: no pain, 10: worst pain you have ever felt)Do you drink alcohol? Yes No If yes, how many drinks, on average, per week?Do you smoke cigarettes? Yes No If yes, how many packs per day?Do you smoke e-cigarettes? Yes No If yes, how often?Recent weight gain or loss? Gained Lost PoundsDo you drink caffeine? Yes No If yes, what type?If yes, how many drinks per day? Past breast problems (abnormal imaging, biopsies, and surgeries):Side Right Side Left Side Please describe the problem in the right side.Please describe the problem in the left side?Have you ever taken any hormones? Yes No Please select all of the hormones you have taken. Birth Control Pills Are you currently on birth control? Yes No Type/Name of Hormone-Birth Control PillsHow many years have you taken Birth Control? Estrogen Are you currently taking Estrogen? Yes No Type/Name of Hormone-EstrogenHow many years have you taken Estrogen? Tamoxifen Are you currently taking Tamoxifen? Yes No Type/Name of Hormone-TamoxifenHow many years have you taken Tamoxifen? Evista (Raloxifene) Have you ever taken Evista (Raloxifene)? Yes No Type/Name of Hormone-Evista (Raloxifene)How many years have you taken Evista (Raloxifene)If other, please specify the name and type of hormone, how many years you have taken it, and if you are currently on it.Age of onset of menstruationHave you gone through menopause? Yes No If so, at what age?If no, what is the interval between periods?Duration of periods:Date of last period:Have you ever been pregnant? Yes No Number of pregnanciesNumber of birthsNumber of miscarriagesNumber of abortionsAge at first childbirthDid you breastfeed? Yes No If so, how long?Do you have a family history of breast cancer? Yes No If yes, who had breast cancer and at what age?Do you have a family history of ovarian cancer? Yes No If yes, who had ovarian cancer and at what age?If you are unsure about cancer within your family history, please check Do Not Know Medical Problems: Select all that apply High blood pressure Diabetes Heart problems History of heart attacks History of stroke Hyperthyroid Hypothyroid Fibromyalgia Depression Other If other, please state the type of medical problem.Past Surgery/Operations:In chornological order please list past surgeries or operations including, the reasons for surgery, the year, and if possible the hospital and physician taking care of you.Hospitalizations:In chronological order please list the reasons you have been hospitalized, year of hospitalization and if possible, the hospital and physician taking care of you. Are you allergic to any medicines? Yes No Please list any medications to which you have had an allergic reaction, and the type of reaction:Are you allergic to any foods? Yes No Please list any foods to which you have had an allergic reaction, and the type of reaction:Are you currently taking any of the following? Hormone or birth control Antidepressant/antianxiety pills Tranquilizers/sleeping pills Pain pills Blood thinners List any vitamins, herb, or therapy you are taking, and include the dosage and frequency.Have you have had radiation therapy in the past? Yes No Month/year treatment startedMonth/year treatment stoppedArea of bodyHospitalDoctor who treated you Have any of your blood relatives had cancer? Please check all that applyHiddenHave any of your blood relatives had cancer? Please check all that apply. Breast Who and what age?Have any of your blood relatives had cancer? Please check all that apply. Ovarian Who and what age?Have any of your blood relatives had cancer? Please check all that apply. Colon Who and what age?Have any of your blood relatives had cancer? Please check all that apply. Thyroid Who and what age?Have any of your blood relatives had cancer? Please check all that apply. Pancreas Who and what age?Have any of your blood relatives had cancer? Please check all that apply. Prostate Who and what age?Have any of your blood relatives had cancer? Please check all that apply. Lung Who and what age?Have any of your blood relatives had cancer? Please check all that apply. Skin Who and what age?Have any of your blood relatives had cancer? Please check all that apply. Lymphoma Who and what age?Have any of your blood relatives had cancer? Please check all that apply. Leukemia Who and what age?Have any of your blood relatives had cancer? Please check all that apply. Other If other, please state the type of cancer, who had it, and their age.Example: Type: Prostate Cancer, Relation: Father, Age: 50Have any of your blood relatives had any of the following Tuberculosis Diabetes Anemia Bleeding Tendency Heart Disease High Blood Pressure Kidney Disease Asthma, Hay Fever, Other Allergy Chronic Arthritis (Rheumatism) Nervous Or Mental Disorder Goiter Emphysema Any Other Illness List Any Other IllnessList Any Other IllnessCAPTCHA Δ
