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 NameLast Name
DOB:

MonthDayYear
Age:
Sex:

MaleFemale
Height/Weight:
Preferred Language:

EnglishOther
Address

Street Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Home Phone:
Cell phone:
Alt. Phone
Emergency Contact Name:
Emergency Contact Phone Number:
INSURANCE INFORMATION
Insurance Co:
Policy #:
Group #:
Policy Holder:
Policy Holder DOB:

MonthDayYear
Date
Relationship to Patient:
Policy Holder Address:

Street Address

Street Address Line 2

CityState / Province

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

MonthDayYear
Date
Relationship to Patient:
Policy Holder Address:

Street Address

Street Address Line 2

CityState / 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?

YesNo
Do you have a healthcare Power of Attorney?

YesNo
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

YesNo
Marital Status:

SingleMarriedDivorcedWidowed
Do you have children?

YesNo
How many?
Ages of children:
Religious preference:
Do you currently smoke or have a past history of using tobacco products?

YesNo
Do you drink alcohol?

YesNo
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?

YesNo
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?

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

YesNo
If yes, were the ovaries removed?

YesNo
Do/did you use birth control pills?

YesNo
If yes, for how many years:
Do/did you use estrogen/hormone replacement therapy?

YesNo
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 appetiteChange in weightFatigueGeneralized weaknessFever or chillsNight sweatsFrequent coldsNone
Eyes

Change in visionEye PainDouble visionNoneGlasses/Contacts
Ears, Nose, Mouth, Throat

Hearing problemsNose bleedsSinus troublePost nasal dripDental problemsSore mouth/tongueSore lipsHoarsenessSore throatBleeding gumsNone
Bones, Joints, Muscles

CrampingJoint painSwollen jointsNone
Endocrine

HyperthyroidismHypothyroidismHot FlashesNone
Digestive

Difficulty swallowingFrequent heartburnBelching or excess gasNauseaVomitingDiarrheaConstipationBlack stoolsChange in Bowel habitsRectal bleedingHemorrhoidsAbdominal painNone
Heart

Chest painIrregular heartbeatMurmurSwollen feet/ankle/handsNone
Lungs

Persistent coughCoughing up bloodShortness of breathSputum/ phlegm productionWheezingDifficulty breathing when flatNone
Immunologic

Severe allergic reactionsFrequent/severe infectionsPollen allergies/ hay feverNone
Skin

Rash, hives or itchingChange in colorChange in mole or wartA sore that won’t healNone
Nervous System

HeadachesDizziness or vertigoFaintingConvulsions or seizuresMemory lossPoor coordinationWeaknesses of arms or legsNumbness in arms or legsNone
Genitourinary

Pain/burning with urinationExcessive nighttime urinationExcessive daytime urinationSlow starting or stoppingUnable to hold urineBlood in the urineNoneProstate InfectionsImpotenceVaginal discharge or bleedingPainful intercourse
Blood Disorders

Easy bruisingAbnormal bleedingEnlarged lymph nodesNone
Psychiatric

AnxietyDepressionTrouble sleeping/insomniaWork/family stressNone
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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2
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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)