Fillable Printable Patient Registration Form - Virginia
Fillable Printable Patient Registration Form - Virginia
Patient Registration Form - Virginia
PATIENT’S MEDICAL HISTORY FORM
DRS. FARR, WAMPLER, HENSON, WILLIAMS & DOUGHERTY
Patient’s Name:_________________________________________Date:____________________
What is the reason for your visit today?______________________________________________
______________________________________________________________________________
Please List all of your Medical Problems (current & old)_________________________________
______________________________________________________________________________
______________________________________________________________________________
Please List all of your Previous Surgeries_____________________________________________
Do any of these Medical Problems apply to you? Please Check box to the right of those that do.
Heart Disease
Chest Pain
Heart Murmer
High Blood Pressure
Shortness of Breath
Asthma/Emphysema
Blood with Coughing
Anesthetic Reaction
Diabetes
Thyroid Disease
Arthritis
Kidney Stones
Blood in your Urine
Frequent Urination
Pain with Urination
Depression
Stroke
Nervous Disorder
Back Pain
Blood Transfusion
HIV or Hepatitis
Bleeding Tendency
Diarrhea
Constipation
Stomach Ulcers
Heartburn
Hernia Repairs
CANCER: list type(s)
Please list ALL the MEDICATIONS you are presently taking.___________________________
______________________________________________________________________________
______________________________________________________________________________
Are you ALLERGIC to any MEDICATIONS? (Please list)_____________________________
______________________________________________________________________________
SOCIAL HISTORY:
Do you Smoke? Yes_______ No_______
If Yes, how much a day?__________________ If you stopped, When?___________
Do you Drink Alcohol? Yes_______ No_______
If Yes, how much?_______________________ If you stopped, When?___________
MARITAL STATUS: Single_______Married_______Separated_______Divorced______
Widowed______ How Many Children?_______
FAMILY MEDICAL HISTORY:
Please list any close relatives that have a history of the following diseases: Heart
Disease, Stroke, Diabetes, Cancer? If there are other diseases that run in your family, please list.
______________________________________________________________________________
To the best of my knowledge, the questions on this form
have been accurately answered. It is my responsibility
to inform the doctor’s office of any changes in my medical
status. I also authorize the healthcare staff to perform
the necessary services that I may need.
X_____________________________________
Signature of Patient or Guardian Date
Office use only:
Date:
Breast History Information:
Drs. Farr, Wampler, Henson, Williams, Dougherty & Brown
www.novasurgery.com
Name: Date:
Who Referred you to us?
__________________________
What is the Reason for your visit today? (Please Circle)
[Right] or [Left] or [Both] breasts?
Abnormal Mammogram or Ultrasound?
Breast Lump?
Nipple Discharge?
Breast Pain?
OTHER REASON? _______________________________________
Has anyone in your family ever had Breast or Ovarian Cancer?
(Please list their age at diagnosis.)
“Mother’s side” “Father’s side”
Grandmother ___________________________________________________
Mother _________________________________________________________
Daughter _______________________________________________________
Sister __________________________________________________________
Aunt ___________________________________________________________
Birth Control Pills: Have you ever taken them? Yes No
If yes, How many total years did you take them?______________________
Have you taken hormone replacement? Yes No
If yes, name of drug? _______________ For how many years? ___________
Menstrual (“Period”) History:
At what age did you begin your “Period”? ____________________________
How old we re you when you had your 1
st
child? _______________________
How many children have you had? __________________________________
Previous Breast Procedures: (Please circle)
Cyst Aspirations: None Left Right
Breast Biopsy: None Left Right
Breast Cancer Surgery: None Left Right
Did you Breastfeed your children?
Yes No
Have you had a Hysterectomy?
Yes No
(Removal of your uterus or “womb”)
Have you had your ovaries removed? Yes No
(ie: sometimes performed with a hysterectomy)
Drs. Farr, Wampler, Henson, & Williams, Ltd.
General, Vascular, Thoracic & Breast Surgery
www.NOVASURGERY.com
Breast Care Responsibility Agreement
WHAT YOU NEED TO KNOW:
It is common that patients do not return for office visits or breast
imaging studies as recommended. Return visits and breast imaging studies
(ie: mammograms) are frequently recommended 6 to 12 months in advance.
Unfortunately, we are not equipped to track every patient’s follow-up plan.
We will not call to remind you when to return to see your surgeon…or for
every test result. DO NOT ASSUME THAT IF YOU DO NOT HEAR
FROM US, EVERY THING IS O.K.! A delay in the diagnosis and
treatment of breast cancer may occur if you do not follow our
recommendations.
We rely on you to help us provide good care by implementing our
recommended treatment and follow-up plan.
OUR COMMITMENT TO YOU:
Your surgeon will outline a detailed plan for your care. You will
leave our office with the appropriate order forms and follow-up visit
recommendations. We typically see you in our office after follow-up
imaging studies and review the results in person with you. Even we can
miss or overlook aspects of your care. If you ever recognize this, please call
and bring it to our attention. Our practice does not coordinate general breast
cancer screening (see reverse for guidelines). We recommend you
coordinate this with your primary care physician.
YOUR RESPONSIBILITY:
1. Keep track of your return visits and breast imaging orders at
home. (Place a reminder in your calendar.)
2. Coordinate these visits and imaging studies yourself.
3. Call us for any questions or concerns.
4. Call us if you feel we have not done our job well.
***ONLY TOGETHER CAN WE ACHIEVE THE BEST IN BREAST CARE***
I acknowledge that I have received a copy of this sheet for my review and records.
Name:_____________________________________
Date:____________
Breast Care Responsibility Statement Cont’d
(Additional Information)
A Few Important Reasons for Breast Surgeon Follow-up Visits
and Imaging Studies:
1. “Indeterminante” imaging results
•
When a mammogram or ultrasound or MRI suggests that there is a
tiny risk of a cancer (usually less than 3%). A repeat exam is often
recommended in 3 – 6 months by the radiologist to detect any change
that would more strongly suggest there is a cancer present.
2. If you have had Breast Cancer
3. Women deemed a “High Risk” for developing breast cancer
4. After a Stereotactic Breast Biopsy
5. Often after an breast surgery
6. A repeat surgeon breast exam is suggested
Breast Cancer Screening Guidelines
[American Cancer Society]
Yearly mammograms are reco mmended starting at age 40 and continuing
for as long as a woman is in good health.
Clinical breast exam (CBE) should be part of a periodic health exam, about
every 3 years for women in their 20s and 30s and every year for women 40
and over.
Women should know how their breasts normally feel and report any breast
change promptly to their health care providers. Breast self-exam (BSE) is an
option for women starting in their 20s.
Women at high risk (greater than 20% lifetime risk) should get an MRI and
a mammogram every year. Women at moderately increased risk (15% to
20% lifetime risk) should talk with their doctors about the benefits and
limitations of adding MRI screen ing to their yearly mammogram. Yearly
MRI screening is not recommended for women whose lifetime risk of breast
cancer is less than 15%.
