DEMOGRAPHICSPLEASE PRINT CLEARLY

PATIENT INFORMATION EMAN # CES LAICOS SSERDDA

CITY STATE/ZIP

AGEOCCUPATION

MARITAL STATUS SPOUSE’S NAME # ENOHP

# XAF # LLEC

PRIMARY INSURANCE SECONDARY INSURANCE REIRRAC REIRRAC# REBMEM # REBMEM# PUORG # PUORGSSERDDA SSERDDAPIZ/ETATS/YTIC PIZ/ETATS/YTIC# ENOHP # ENOHP

INSURANCE GUARANTOR EMPLOYER INFORMATION EMAN .PMOC EMAN REDLOHSSERDDA NSS REDLOHYTIC .B.O.D REDLOHPIZ/ETATS# ENOHP# XAF

PHYSICIAN INFORMATION REFERRING M.D. FAMILY M.D.

# ENOHP # ENOHP# XAF # XAFSSERDDAYTIC TSIGOLOCNOPIZ/ETATS # ENOHP

# XAFENTRUSTED CONTACTS

EMAN EMAN PIHSNOITALER PIHSNOITALERSSERDDA SSERDDAYTIC YTICPIZ/ETATS PIZ/ETATS

# EMOH # EMOH# LLEC # LLEC # KROW # KROW

EMAIL BIRTH DATE

Dr. Kenneth M. Tokita, Radiation Oncologist

er revoked, it shall terminate one year

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Patient Name: Today’s Date:

SURGICAL PROCEDURES Procedure and Date:

SOCIAL HISTORY (Check Appropriate Answer)

Smoking: No Yes :sraeY fo rebmuN:ycneuqerF

Years Since Quitting:AlcoholConsumption: No Yes :sraeY fo rebmuN:ycneuqerF

Years Since Quitting:

Prior Radiation Therapy (Site Treated, Name of Center, Date)

Occupation (If Ret ired, Previous Occupation)

Marital Status and Number of Children

City Where You Currently Live

ALLERGIES Drug and Response (Example: Penicillin Results in Hives)

MEDICAL PROBLEMS Problem (Onset Date)

Have you been diagnosed with lupus, rheumatoid arthritis, collagen vascular disease, or ulcerative colitis?

If so, do you take steroids such as prednisone?

Ht:

Wt:

Cancer Center of IrvineHEALTH QUESTIONNAIRE

PLEASE PRINT CLEARLY

Alive Age at Death, Cause of Death, and Any Medical Problems (Including Cancer)

FAMILY HISTORY (Check Appropriate Answer)

Father No Yes

Mother No Yes

Son No Yes

Daughter No Yes

Other Relative No Yes

Date of Birth:Age:

Reason for today’s visit

Please list all

First Name of Spouse

REVIEW OF SYSTEMS Do you have the following?

General Gastrointestinal (Continued) Relatively Good Health Most of Your Life No Yes Bleeding with Bowel Movements No Yes Weight Change Over Past 6 mos. +/- lbs. No Yes Heartburn or Indigestion No Yes

Cramping No YesSkin Trouble Swallowing No Yes Serious Skin Problems No Yes Black Stools No Yes Jaundice No Yes Hemorrhoids or Piles No Yes Hives, Rashes, or Eczema No Yes Recent Change in Bowel Habits No Yes Infections or Boils No Yes Frequent Diarrhea No Yes Unusual Pigmentation No Yes Regular Bowel Movements No Yes

HeadGynecological (If Applicable) Serious Headaches or Injuries No Yes

Gynecological Problems No YesCurrently Pregnant

No Yes

Eyes

Date of Last Pregnancy Test Glasses No Yes

Age When Period Started Condition:

Age at First Delivery Serious Eye Diseases or Injuries No Yes

Number of Pregnancies Double Vision No Yes

Number of Miscarriages Glaucoma No Yes

Age When Periods Ended Menopause Reason, e.g. Surgery

Ears, Nose and Throat

# Yrs of Contraceptive Hormone Use Runny Nose No Yes

# Yrs of Postmenopausal Hormone Use Nosebleeds No Yes

Date and Results of Last Pap Smear Impaired Hearing No Yes

Dizziness or Episodes of Unconsciousness No Yes

Date and Results of Last Mammogram Throat Problems No Yes

Respiratory

Musculoskeletal No Yes

Arthritis; (Circle: Osteo or Rheumatoid) No Yes

Chronic Cough No Yes

Muscle-Joint Weakness or Diseases No Yes

Asthma or Wheezing No

YesShortness of Breath No Yes

Neurological

Pleurisy or Pneumonia No Yes

Fainting Spells No Yes

Convulsions

No YesNeck

Paralysis No Yes

Thyroid Illnesses No Yes

Strokes No Yes

Glandular Enlargement No Yes

Head Injuries No YesSeizures

No Yes

Cardiovascular Chest Pain or Angina Pectoris / SOB No Yes

Hematological Shortness of Breath While Resting No Yes

Bruise Easily or Heal Slowly No Yes

Heart Trouble or Heart Attacks No Yes

Blood Disease No Yes

Date(s):

Anemia No Yes

High Blood Pressure / Hypertension No Yes

Last Colonoscopy

Swelling of Hands, Feet or Ankles No Yes

Unusual Bruising No Yes Other Known Heart Disease No Yes

Bleeding with Injuries or Dental Work No Yes

Specify:

PsychiatricGastrointestinal

Psychiatric History No Yes Peptic Ulcer (Stomach or Duodenal) No

Yes Vomiting Blood No Yes

EndocrineLiver Trouble

No Yes

Hormonal Problems No YesHepatitis; If Yes A, B, or C (Circle One)

No Yes Endocrine Problems No Yes Painful Bowel Movements No

CPAP / Sleep Apnea

Date:

YesNo YesDiabetic

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This Column to be Completed by Physician or Nurse Only

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KSK Medical, LLC16100 Sand Canyon Avenue • Suite 130 • Irvine • CA • 92618 • Phone 949.417.1100 • Fax 949.417.1165

 

 

 

Legislation has recently been enacted that requires healthcare facilities to adopt an Electronic Medical Records system and utilize the system to report specific data.  The following questions are intended to fulfill this requirement.  KSK Medical would like to assure you that your answers to these questions will have absolutely no impact on your care.  You may opt to not answer any question by marking or writing “Decline to Answer.”    Thank you very much for your understanding.     

Ethnicity:   

Hispanic or Latino

     Not Hispanic or Latino 

 Unknown 

     Decline to Answer 

 

Race:  _________________________________      Decline to answer 

 

Preferred Language:  _______________________________ 

 

When necessary, how would you like to receive the following?          

 

Clinical Summary          Print Copy          Email          Portable Media          Patient Portal 

 

General Preference  Print Copy          Email          Portable Media          Patient Portal 

 

Patient Information  Health Information    Visit Summary   Reminders    Summary of Care 

 

Patient Reminders  Text Message (Cell #_________________ Cell Phone Company______________ )   

  Email  (Email Address _______________________________________________)                              

  Do Not Send  

 

Summary of Care  Print Copy          Email          Portable Media          Patient Portal 

 

 

Print Patient Name:  _____________________________________  Date:  __________________   

 

Patient Signature:  _______________________________________ 

Medical Information Release Form

(HIPAA Release Form)

Name: ___________________________________ Date of Birth: _____/____/_____

Release of Information[ ] I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to:

[ ] Spouse________________________________________

[ ] Child(ren)______________________________________

[ ] Other__________________________________________

[ ] Information is not to be released to anyone.

This Release of Information will remain in effect until terminated by me in writing.

MessagesPlease call [ ] my home [ ] my work [ ] my cell Number:__________________

If unable to reach me:

[ ] you may leave a detailed message

[ ] please leave a message asking me to return your call

[ ] __________________________________________

The best time to reach me is (day)___________________ between (time)_________

Signed: ______________________________________ Date: ____/____/_____

Witness:______________________________________ Date: ___/____/______