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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
Plea
se li
st a
ll of
the
Doc
tors
you
are
seei
ng so
that
we
may
kee
p th
em in
form
ed o
f you
r pro
gres
s.
Nam
e of
Doc
tor
Spec
ialit
y Ph
one
Num
ber
Fax
Num
ber
Add
ress
(S
tree
t, C
ity, S
tate
, Zip
)
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
DA
TE
DA
TE
Alle
rgie
s:
Me
dic
ati
on
Na
me
Dose
How
O
ften?
New
Acti
on
New
Acti
on
A=
Add
A=
Add
R=
Resum
eR
=R
esum
e
S=
Sto
pS
=S
top
Pa
tie
nt
Den
ies t
akin
g a
ny m
ed
icatio
n,
vita
min
s o
r he
rba
ls
Nam
e o
f P
harm
acy :____________________________
City/
Cro
ss s
treet: _
_____________________________
Phone #
_____________________________________
Ph
ysic
ian
's
Sig
na
ture
D
ate
Pharm
acy c
alle
d: _
_______________________________
How
Many
Per
Dose?
113 4 5 6
(Exactly a
s w
ritten o
n b
ottle
or
pre
scription)
(p
res
cri
pti
on
, o
ve
r-th
e-c
ou
nte
r, v
ita
min
s &
he
rba
l)
ME
DIC
AT
IO
N R
EC
ON
CIL
IA
TIO
N F
OR
M
Exa
mp
le:
Blo
od
Pre
ssu
re,
He
art
,
Sle
ep
, N
erv
es
En
ter
?
If U
nkn
ow
n
7 8 9
This Column to be Completed by Physician or Nurse Only
121 2
NA
ME
:____________________________ D
OB
:___________ H
eig
ht:
_______ W
eig
ht:
_________
exam
ple
:
325m
g,
5m
g/m
l,
100units/c
c
exam
ple
:
2 t
able
ts,
1 t
easpoon,
3cc
exam
ple
: tw
ice d
aily
, every
4 h
ours
10
Medic
ation P
urp
ose
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: ___/____/______