PG. 1

OPTIONAL INFORMATION

*Race: Asian White American Indian/ Native American

Hispanic / Latino

Hawaiian / Other Pacific Islander

Black / African American

More than one race Refuse to answer

*Ethnicity: Hispanic / Latino Not Hispanic/ Latino Refuse to answer *Preferred Language *As part of an effort to improve health care, the US Government requires that we ask these questions.

REASON FOR VISIT:________________________________________________________________________________

Signature of Patient/Legal Guardian: _______________________________________Date:______________________

PATIENT INFORMATION Name: Date of Birth: Age: Gender: Social Security Number: Marital Status: Street Address: City: State: Zip: Home Phone: Cell Phone: Email: Employer: Work Phone: Oncology Physician: Preferred Pharmacy: Location:

RESPONSIBLE PARTY (IF PATIENT IS UNDER 18 YEARS OLD) Name: Date of Birth: Age: Gender: Social Security Number: Marital Status: Street Address: City: State: Zip: Home Phone: Cell Phone: Email: Employer: Work Phone:

EMERGENCY CONTACT INFORMATION Emergency Contact Name: Address:

Phone:

Relationship: INSURANCE INFORMATION

Primary Insurance: Secondary Insurance: Certification#: Certification#: Subscriber Name: Subscriber Name: Subscriber DOB: Subscriber DOB: Subscriber Sex: M / F Subscriber Sex: M / F

PG. 2

Health History Patient: DOB: Age: Gender:

Allergies: List anything that you are allergic to (medications, food, bee stings, etc.) and how each affects you. Allergy Reaction Date of Incident

Medications: Please list all of the medication you are taking, including over-the-counter and vitamins.

Medication Strength Frequency Taken Health Maintenance:

Test Date Result (Please Circle) Complete Physical Normal Abnormal Colonoscopy Normal Abnormal Lipid (Cholesterol) Normal Abnormal Eye Exam Normal Abnormal PSA (Men 50-70 y.o.) Normal Abnormal PAP Smear (Women) Normal Abnormal Mammogram (Women) Normal Abnormal

Immunization Date Immunization Date Pneumonia Shot Flu Shot Tetanus Meningitis Gardasil (HPV) Other Childhood Immunizations up-to-date? Yes No Social History: Check all that apply Tobacco: ____ Current Every Day Smoker ______ Current Some Days Smoker # _____ Packs Per Day _____ Former Smoker ______ Never a Smoker ______ Use Chewing Tobacco Alcohol Use: NO YES How much per day? Drug Use: NO YES How much per day? Exercise: NO YES What kind of exercise? How often do you exercise? Marital Status: ___ Single ___ Married ___Separated ____ Divorced ____ Widowed Level of School Completed: Assignment of Benefits: I hereby assign to Grand Valley Oncology any insurance or other third party benefits available for health care services provided to me. I understand that GVO has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to GVO, I agree to forward to the practice all health insurance and other third party payments I receive for services rendered to me immediately upon receipt.

Signature of Patient/Legal Guardian: __________________________________ Date: _________________________

PG. 3

Patient: DOB: Age: Gender:

Please mark any symptoms you are experiencing that are related to you complaint today.

Allergic/Immunologic Ears/Nose/Mouth/Throat Genitourinary Men Only Frequent Sneezing Bleeding Gums Pain with Urinating Pain/Lump Testicle Hives Difficulty Hearing Blood in Urine Penile Itching, Burning

or Discharge Itching Dizziness Difficulty Urinating Runny Nose Dry Mouth Incomplete Emptying Problems Stopping or

Starting Urine Stream Sinus Pressure Ear Pain Urinary FrequencyCardiovascular Frequent Infections Loss of Urinary Control Waking to urinate at

night Chest Pressure / Pain Frequent Nosebleeds Hematologic / Lymphatic Chest Pain on Exertion Hoarseness Easy Bruising / Bleeding Sexual problems or

concerns Irregular Heart Beats Mouth Breathing Swollen Glands Lightheaded Mouth Ulcers Integumentary (Skin) History of Sexually

Transmitted Diseases Swelling (Edema) Nose/Sinus Problems Change in Moles Shortness of Breath

When Lying Down Ringing in Ears Dry Skin Women Only Endocrine Eczema Bleeding Between

Periods Shortness of Breath When walking

Increased Thirst / Urination Growth / Lesions Heat / Cold Intolerance Itching Heavy Periods

Constitutional Gastrointestinal Jaundice (Yellow Skin/ Eyes) Extreme Menstrual Pain Exercise Intolerance Abdominal Pain Rash

Fatigue Black / Tarry Stool Respiratory Vaginal Itching, Burning or Discharge Fever Blood in Stool Cough

Weight Gain (___ lbs) Change in Appetite Cough Up Blood Waking to Urinate at Night Weight Loss (___lbs) Frequent Indigestion Shortness of Breath

Travel Within 10 Days Where:

Hemorrhoids Sleep Apnea Hot Flashes Trouble Swallowing Snoring Breast Lump

Eyes Vomiting Wheezing Breast Pain Dry Eyes Constipation Difficulty Breathing Nipple Discharge Eye Irritation Diarrhea Neurological No Periods Vision Changes Nausea Dizziness Painful IntercoursePsychiatric Musculoskeletal Fainting History of Sexually

Transmitted Disease Anxiety / Stress Back Pain Headache / Migraines Depression Joint Pain Memory Loss Do Not Feel Safe in

Relationship Muscle Aches Numbness Muscle Weakness Restless Legs

Mania Seizures Sleep Problems Weakness Are you sexually active? YES NO Current sexual partner is: Female Male Current Method of Birth Control Used: _______________________________ Women Only: Women Only: Age of First Menstrual Period: ____________ Date of Last Menstrual Period: _________________ Age at Menopause: _____________ Number of Pregnancies: _______ Live Births: ______

PG. 4

Patient: DOB: Age: Gender:

Please check any significant medical history in yourself or family members. Past Surgical History:

Surgery Reason Year Hospital

Condition SELF Father Mother Sibling Mother’sParent(s)

Father’s Parent(s)

Details

Alcoholism Anemia Anxiety Arthritis Asthma Birth Defects Blood Clots Bowel Problems Cancer – Type COPD Depression Diabetes Eye Disease Epilepsy / Seizures Heart Attack Heart Disease Heart Murmur Heartburn / Reflux High Blood Pressure High Cholesterol Kidney Disease Liver Disease Lung Disease Mental Illness Type:

Migraines Stomach Ulcer Stroke Suicide / Suicide Attempt

Thyroid Disease Tuberculosis Other:

Patient Name: {Patient.NameLFI} Medical Record Number: {Ident.IDA} DOB: {Admin.Birth_Date}

1. Weight

I currently weight ___________ lbs

I am __________feet _________ inches tall

*One month ago, I weighed_________ lbs

**Six months ago, I weighed ________ lbs

Have you lost weight on purpose?

☐ Yes ☐ No

During the past two weeks, my weight has:

☐ Decreased (1)

☐ Increased (0)

☐ Not changed (0)

2. Food Intake:

As compared to my normal intake, I would

rate my food intake during the past month

as: ☐ Unchanged (0)

☐ More than usual (1)

☐ Less than usual (1)

I am now taking:

☐ Normal food, less amount (1)

☐ Little solid food (2)

☐ Only liquids (2)

☐ Only nutrition supplements (3)

☐ Very little of anything (4)

☐ Only tube feeding (4)

3. Symptoms:

During the past two weeks, I have had the

following problems which kept me from

eating enough (check all that apply):

☐ No problems (0) ☐ Feel full quickly (1)

☐ Nausea (1) ☐ Dry mouth (1)

☐ Constipation (1) ☐ Taste changes (1)

☐ Smells bother me (1)

☐ Problems swallowing (2)

☐ Mouth sores (2) ☐ Diarrhea (3)

☐ No appetite (3) ☐ Vomiting (3)

☐ Pain; Where? (3) __________________

☐ Other (1) ________________________ (Examples: money, dental issues, family)

4. Activities and Function:

Over the past month, I would rate my activity

as:

☐ Normal, no limitations (0)

☐ Not my normal self, but able to perform

regular activities (1)

☐ Not feeling up to most things, but in

bed/chair less than 50% of the day (2)

☐ Able to do little activity and spend more

than 50% of the day in the bed/chair (3)

☐ Bedridden, rarely out of bed (3)

Grand Valley Oncology Malnutrition Screen (Adapted from the Patient-Generated Subjective Global Assessment)

Please fill out this form to the best of your ability, you do not need to calculate your total scores.

The information will help us to determine if you are at risk for malnutrition. Our dietitian will be

available to you during and after your cancer treatment to help you address nutrition concerns

and to answer questions. This is a free service to our patients.

1: Total 2: Total

3: Total 4: Total

Patient Name: {Patient.NameLFI} Medical Record Number: {Ident.IDA} DOB: {Admin.Birth_Date}

GVO Staff use only: % Weight Changes & Total Points

*1 month % change: ☐ 0-1.9% (0) ☐ 2-2.9% (1) ☐ 3-4.9% (2) ☐ 5-9.9% (3) ☐ >10% (4)

Equation: Weight 1 month ago – current weight = ________. Then: _______ / weight 1 month ago = _______ x 100 = the % weight lost

Example: Weight 1 month ago: 100 lbs

Current weight: 90 lbs

100 lbs – 90 lbs = 10 lbs 10 lbs / 100 lbs = 0.1 0.1 x 100 = 10% (4 points)

**6 month % change: ☐ 0-1.9% (0) ☐ 2-5.9% (1) ☐ 6-9.9% (2) ☐ 10-19.9% (3) ☐ >20% (4)

Equation: Weight 6 months ago – current weight = ________. Then: _______ / weight 6 months ago = _______ x 100 = the % weight lost

Example: Weight 6 month ago: 110 lbs

Current weight: 90 lbs

110 lbs – 90 lbs = 20 lbs 20 lbs / 110 lbs = 0.18 0.18 x 100 = 18% (3 points)

Medical assistant to calculate total score; malnutrition screen to be scanned into patient’s chart. Patients with

moderate or high risk require a referral to the dietitian, please send a QCL.

Patient risk level: ☐ Minimal risk (0-3 pts) ☐ Moderate risk (4-7 pts) ☐ High risk (>8 pts)

No initial intervention necessary for minimal risk. Patients screened at moderate risk will receive written education based on symptoms. High risk patients will be contacted during cancer treatment or scheduled

for a MNT appointment.

Date received: ______________

Patient score: _______________

MA Signature: _______________________

TOTAL

TOTAL

{Co

nfi

g.I

nst

_N

am

e},

{Con

fig.A

dr1

} {C

on

fig.C

ity},

{C

on

fig.S

tate

_P

rovin

ce}

{Co

nfi

g.P

ost

al}

Pat

ient

Nam

e: {

Pati

ent.

Nam

eLF

I}

Med

ical

Rec

ord

Num

ber

: {I

den

t.ID

A}

DO

B:

{Ad

min

.Bir

th_D

ate

}

Pag

e 1 o

f 1

NC

CN

DIS

TRES

S TH

ERM

OM

ETER

Inst

ruct

ion

s: P

leas

e ch

eck

the

nu

mb

er (

0 –

10)

th

at b

est

d

escr

ibes

ho

w m

uch

dis

tres

s yo

u h

ave

bee

n e

xper

ien

cin

g in

th

e

pas

t w

eek

incl

ud

ing

tod

ay.

PR

OB

LEM

LIS

T

Ple

ase

ind

icat

e if

an

y o

f th

e f

ollo

win

g h

as b

een

a p

rob

lem

fo

r yo

u in

th

e p

ast

wee

k in

clu

din

g to

day

.

Be

su

re t

o s

ele

ct Y

es

or

No

fo

r e

ach

qu

esti

on

.

Ex

trem

e D

istr

ess

N

o D

istr

ess

P

ract

ical

Pro

ble

ms

Ch

ild C

are

Ho

usi

ng

Insu

ran

ce/F

inan

cial

Tra

nsp

ort

atio

n

Wo

rk/S

cho

ol

Tre

atm

ent

Dec

isio

ns

Fam

ily P

rob

lem

s

Dea

ling

wit

h C

hild

ren

Dea

ling

wit

h P

artn

er

Ab

ility

to

hav

e C

hild

ren

Fam

ily H

ealt

h Is

sues

Em

oti

on

al P

rob

lem

s

Dep

ress

ion

Fea

rs

Ner

vou

snes

s

Sad

ne

ss

Wo

rry

Lo

ss o

f In

tere

st in

usu

al a

ctiv

itie

s

Sp

irit

ual

/Rel

igio

us

Co

nce

rns

Oth

er:

Ph

ysic

al P

rob

lem

s

Ap

pea

ran

ce

Bat

hin

g/D

ress

ing

Bre

ath

ing

Ch

ange

s in

Uri

nat

ion

Co

nst

ipat

ion

Dia

rrh

ea

Eat

ing

Fat

igu

e

Fee

ling

Swo

llen

Fev

ers

Get

tin

g A

rou

nd

Ind

iges

tio

n

Mem

ory

/Co

nce

ntr

atio

n

Mo

uth

So

res

Nau

sea

No

se D

ry/C

on

gest

ed

Pai

n

Sex

ual

Ski

n/D

ry It

chy

Sle

ep

Su

bst

ance

Ab

use

Tin

glin

g in

Han

ds/

Feet