NEW PATIENT FORM

Folsom Medical Office

1631 Creekside Drive, Suite 102
Folsom, CA 95630

(916) 250-0377

hoaonc.com

Elk Grove Medical Office

9390 Big Horn Blvd, Suite 145
Elk Grove, CA 95758

(916) 573-1549

hoaonc.com

NEW PATIENT FORMS
PATIENT NAME:
DOB:
Referring Physician:
Primary Care Physician:

	Physician Name	Specialty	Contact Info
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PATIENT INFORMATION
Name

First Name Last Name
DOB:

Month Day Year
Age:
Sex:

Male Female
Height/Weight:
Preferred Language:

English
Address

Street Address

Street Address Line 2

City, State, Zip
Home Phone:
Cell phone:
Alt. Phone
Emergency Contact Name:
Emergency Contact Phone Number:
INSURANCE INFORMATION
Insurance Co:
Policy #:
Group #:
Policy Holder:
Policy Holder DOB:

Month Day Year
Date
Relationship to Patient:
Policy Holder Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Policy Holder Employer:
Employer Phone No:
Secondary Insurance Co:
Policy #:
Group #:
Policy Holder:
Policy DOB:

Month Day Year
Date
Relationship to Patient:
Policy Holder Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Policy Holder Employer:
Employer Phone No:
Please let the front desk know about additional insurance or medical spending plans.
ADVANCE DIRECTIVES:
Do you have an advance directive?

Yes No
Do you have a healthcare Power of Attorney?

Yes No
If yes to any of the above, please provide a copy to our staff.
Brief reason for visit:

PERSONAL MEDICAL HISTORY

	Check if Yes	Family History
Anemia
Arthtitis
Asthma
Blood Disorder
Colitis
Diabetes
Emphysema/COPD
Epilepsy
Exposure to abestos
Heart Disease
Hepatitis Type
High Blood Pressure
Irregular Heart Beat
Kidney Disease
Liver Disease
Mentall Illness
Migraine Headaches
Pneumonia
Sexually Transmitted Disease
Sleep apnea
Stroke
Thyroid Disease
Tuberculosis
Ulcer

PREVIOUS CANCER HISTORY (IF APPLICABLE):

Please list the treated cancer type and treatment dates.

	Type of Cancer	Radiation Therapy Type	Date	Chemotherapy Regimen	Date	Hormone Therapy	Date
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2
3

SOCIAL HISTORY
Occupation (previous if retired)
Retired

Yes No
Marital Status:

Single Married Divorced Widowed
Do you have children?

Yes No
How many?
Ages of children:
Religious preference:
Do you currently smoke or have a past history of using tobacco products?

Yes No
Do you drink alcohol?

Yes No
If yes, how many days/week do you consume alcohol?
How many drinks/day?
If you previously drank alcohol, when did you stop?
Do you use any recreational drugs?

Yes No
Type
FAMILY HISTORY

Please include age at diagnosis

	Breast Cancer	Ovarian Cancer	Colon Cancer	Lung Cancer	Prostate Cancer	Other Cancer	Age of Diagnosis
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Father
Mother
Brother(s)
Sister(s)
Son(s)
Daughter(s)

IMMUNIZATION HISTORY:

Please check all immunizations received and the date of last vaccine.

	Check if Yes	Date of Vaccine
Chickenpox
Flu
Hemophiles (HIB)
Hepatitis B
Measles
Pneumococcal
Polio
Smallpox
Tetanus

	Specify Vaccine Name	Date of Vaccine
Other
Other
Other

OBSTETRICS/GYNECOLOGICAL HISTORY (if applicable)
Age of menarche:
Date of last period?

Month Day Year
Date
Age at menopause (If applicable)?
Age at first full pregnancy:
Number of pregnancies:
Number of births:
Have you had a hysterectomy?

Yes No
If yes, were the ovaries removed?

Yes No
Do/did you use birth control pills?

Yes No
If yes, for how many years:
Do/did you use estrogen/hormone replacement therapy?

Yes No
If yes, for how many years:
HOSPITALIZATIONS AND SURGICAL HISTORY

	Surgical Procedures/ Hospitalizations	Name of admitting physician	Hospital	Date
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ROUTINE CANCER SCREENING TEST

List last date if known

	Check if Yes	Date
Mammogram
Self Breast Exam
PAP Smear/ Pelvic Exam
Stool For Occult Blood

	Check if Yes	Date
Prostate Exam
Colonoscopy/ Sigmoidoscopy
Other

SYMPTOMS
What is your current pain level on a scale of 10?
Please check if you have the following symptoms:
General

Change in appetite Change in weight Fatigue Generalized weakness Fever or chills Night sweats Frequent colds None
Eyes

Change in vision Eye Pain Double vision None Glasses/Contacts
Ears, Nose, Mouth, Throat

Hearing problems Nose bleeds Sinus trouble Post nasal drip Dental problems Sore mouth/tongue Sore lips Hoarseness Sore throat Bleeding gums None
Bones, Joints, Muscles

Cramping Joint pain Swollen joints None
Endocrine

Hyperthyroidism Hypothyroidism Hot Flashes None
Digestive

Difficulty swallowing Frequent heartburn Belching or excess gas Nausea Vomiting Diarrhea Constipation Black stools Change in Bowel habits Rectal bleeding Hemorrhoids Abdominal pain None
Heart

Chest pain Irregular heartbeat Murmur Swollen feet/ankle/hands None
Lungs

Persistent cough Coughing up blood Shortness of breath Sputum/ phlegm production Wheezing Difficulty breathing when flat None
Immunologic

Severe allergic reactions Frequent/severe infections Pollen allergies/ hay fever None
Skin

Rash, hives or itching Change in color Change in mole or wart A sore that won’t heal None
Nervous System

Headaches Dizziness or vertigo Fainting Convulsions or seizures Memory loss Poor coordination Weaknesses of arms or legs Numbness in arms or legs None
Genitourinary

Pain/burning with urination Excessive nighttime urination Excessive daytime urination Slow starting or stopping Unable to hold urine Blood in the urine None Prostate Infections Impotence Vaginal discharge or bleeding Painful intercourse
Blood Disorders

Easy bruising Abnormal bleeding Enlarged lymph nodes None
Psychiatric

Anxiety Depression Trouble sleeping/insomnia Work/family stress None
Medications (please bring a list if more than 10 medications or complete the following)

MEDICATIONS

	Name	Dosage	Frequency
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10

DRUG ALLERGIES

	Drug/Reagent	Type of Reaction	Severity (Mild/Moderate/Severe)
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5

Should be Empty:

NEW PATIENT FORMS

PATIENT INFORMATION

INSURANCE INFORMATION

ADVANCE DIRECTIVES:

PREVIOUS CANCER HISTORY (IF APPLICABLE):

SOCIAL HISTORY

FAMILY HISTORY

IMMUNIZATION HISTORY:

OBSTETRICS/GYNECOLOGICAL HISTORY (if applicable)

HOSPITALIZATIONS AND SURGICAL HISTORY

ROUTINE CANCER SCREENING TEST

SYMPTOMS

Medications (please bring a list if more than 10 medications or complete the following)