UCSF Cancer Center New Patient Questionnaire
Patient Name
Date of Birth
Referring Physician
Physician NamePhysician SpecialtyAddressCity StatePhone Fax
Your Other PhysiciansPlease provide the contact information for your other physicians so that we can send them updates on your care here at the Cancer Center.
ZIP
Primary Care PhysicianPhysician NamePhysician SpecialtyAddressCity StatePhone Fax
ZIP
SurgeonPhysician NamePhysician SpecialtyAddressCity StatePhone Fax
ZIP
Medical OncologistPhysician NamePhysician SpecialtyAddressCity StatePhone Fax
ZIP
OtherPhysician NamePhysician SpecialtyAddressCity StatePhone Fax
ZIP
UCSF Cancer Center New Patient Questionnaire
Patient Name
Date of Birth
anaphylaxis/shock short-of-breath
nausea/vomitting itching rash other _____________
eggs
latex
iodine/shellfish
bee stings
intravenous contrast (used in CT scans)
Have you ever had an allergic reaction? Please check all that apply.
Allergies
UCSF Cancer Center New Patient Questionnaire
Patient Name
Date of Birth
Name of Medication or Supplement
Form (tablet, chewable tablet, elixir, etc)
Dosage Strength per Tablet or Liquid Concentration
Amount of Medication per Dose
Frequency, or as needed
Medications and SupplementsDo you take any medications or supplements? Include all prescription, over-the-counter, and topical medications. Include all supplements, vitamins, and herbs.
Your PharmacyPharmacy NameAddressCity StatePhone Fax
ZIP
UCSF Cancer Center New Patient Questionnaire
Patient Name
Date of Birth
Medical HistoryPlease check all that apply.
Arrhythmias or Coronary Artery Disease (CAD)
Anemia (low red blood cell count)
Angina (heart pain from poor blood flow)
Anxiety or Panic Attacks
Arthritis
Asbestos Exposure
Asthma/Bronchitis
Atrial Fibrillation (A Fib or Heart Flutter)
Autoimmune Disease
Bleeding Disorder (Hemophilia)
Blood Disorder
Blood Transfusion (in the past)
Cancer
Chest Pain
Chronic Bronchitis
Chronic Obstructive Pulmonary Disease (COPD)
Cirrhosis (Liver Failure)
Clotting Disorder
Congestive Heart Failure (CHF)
Deep Vain Thrombosis (DVT)
Depression
Diabetes Mellitus - IDDM (taking insulin)
Diabetes Mellitus - NDDM (not taking insulin)
Easy Bruising
Emphysema
Gastroesophageal Reflux Disease (GERD), Acid Reflux, or Heartburn
GI Bleed
Glaucoma
Heart Murmur
Heart Valve Problem
Hepatitis, Chronic
Hiatal Hernia (upper stomach)
HIV/AIDS
Hypertension (High Blood Pressure)
Immune Disorder
Intestinal Disease or Problem
Liver Disease
Lung Disease
Melanoma
Migraine Headaches
Morbid Obesity BMI>=38
Myocardial Infarction (MI or Heart Attack)
Nerve or Muscle Disease
Osteoporosis (loss of bone strength)
Pancreatitis, Chronic
Palpitations, Heart or Fast or Irregular Heartbeats
Peripheral Vascular Disease (PVD)
Psychiatric Treatment (mental health medication)
Pulmonary Embolism (blood clot in lungs)
Renal Disease, Failure, or Insufficiency (CRI)
Seizures or Epilepsy
Sexually Transmitted Infection (STI) or Disease (STD)
Sinus Disorder
Skin Disease
Stomach Ulcer
Stroke, Mini Stroke, or Transient Ischemic Attack (TIA)
Substance Abuse (see later section)
Thyroid Disease
Tuberculosis (TB)
Ulcer, not stomach (open sore that doesn't heal)
Other
Other
UCSF Cancer Center New Patient Questionnaire
Patient Name
Date of Birth
Appendix
Brain
Breast
Caesarean Section (C-Section)
Colon
Coronary Artery Bypass (CABG)
Gallbladder
Heart Valve Replacement (Pacemaker)
Hernia
Hysterectomy
Joint Replacement
Liver
Ovary
Pancreas
Prostate
Spine
Tonsillectomy
Tubal Ligation
Vasectomy
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Date & Comments
Surgical HistoryPlease check all that apply.
Other Date & Comments
Other Date & Comments
UCSF Cancer Center New Patient Questionnaire
Patient Name
Date of Birth
Family History of Cancer
Type of Cancer
Other Medical Conditions
Age at Diagnosis Current Age
If Deceased, Age at Death
Mother
Father
Sister
Sister
Brother
Brother
Daughter
Son
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Other
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Were you adopted? Yes No
Please complete the following table for your biological relatives.
UCSF Cancer Center New Patient Questionnaire
Patient Name
Date of BirthLifestyleDo you drink alcohol?If Yes, what is your average number of: Glasses of Wine per Week
Cans of Beer per WeekShots of Liquor per Week
In regards to smoking, please choose one:
How many years have/did you smoke? At what age did you start smoking?How many packs of cigarettes per day do you/did you smoke?If you quit, when did you quit? (approximate month/day/year)
Do you use smokeless tobacco?
Please check any drugs that you use for recreational use.
Amphetamines
Amyl Nitrate
Anabolic Steroids
Barbiturates
Benzodiazepines
"Crack" Cocaine
Cocaine
Codeine
Fentanyl
GHB
Heroin
Hydrocodone
Hydromorphone
Ketamine
LSD
Marijuana
MDMA Ecstasy
Methamphetamine
Methaqualone
Methylphenidate
Morphine
Nitrous Oxide
Opium
Oxycontin
PCP
Psilocybin
Solvent Inhalants
Other
Other
Yes No
Current Smoker
Never Smoked
Passive Smoker (2nd hand)
Former Smoker
Never UsedFormer UserCurrent User
UCSF Cancer Center New Patient Questionnaire
Patient Name
Date of Birth
Please check all illnesses, problems, and symptoms you have had in the last month.
CONSTITUTIONAL SYMPTOMSActivity changeAppetite changeChillsDiaphoresis (excessive sweating)Fatigue (or malaise)FeverUnexpected weight changeWeakness
EARS/NOSE/MOUTH/THROATNeck painNeck stiffnessHearing lossEar painTinnitus (ringing in the ears)NosebleedsCongestionRhinorrhea (runny nose)Postnasal dripSneezingSinus pressureDental problemTrouble swallowingVoice change
EYESEye dischargeEye painEye rednessPhotophobia (irritation with lights)Visual disturbance (blurred or double vision)
RESPIRATORYApneaChest tightnessChokingCoughShortness of breathStridor (groaning sound while breathing)
CARDIOVASCULARLeg SwellingPalpitations (fluttering in chest)
GASTROINTESTINALAbdominal distention (swelling)Abdominal pain Anal bleedingBlood in stoolConstipationDiarrheaNauseaRectal PainVomiting
URINARYDifficulty urinatingDysuria (burning when you urinate)Enuresis (cannot control urinating)Flank pain (between ribs and hip)Hematuria (blood in urine)Menstrual problem (Females)Pelvic pain (Females)Penile discharge (Males)Penile pain (Males)Penile swelling (Males)Scrotal swelling (Males)Testicular pain (Males)Urgency (need to urinate quickly,
can barely hold it)Urine decreasedVaginal bleeding (Females)
MUSCULOSKELETALBack painGait problemsJoint swellingMyalgias (crampy muscle pain)
SKINPallorWound
NEUROLOGICALFacial asymmetryHeadachesLight-headednessSeizuresSpeech difficultySyncope (fainting)TremorsWeakness
HEMATOLOGIC/LYMPHATICAdenopathy (swelling of lymph nodes)Bleeding or bruising tendency
PSYCHOLOGICALBehavior problemConfusionDecreased concentrationDysphoric (depressed) moodHallucinationsNervous/anxiousSelf-injurySleep disturbance
Review of Symptoms