Thank you for taking the time to complete this form.  Sharing your medical history with us will provide vital information needed for the delivery of high quality and personalized care that you deserve.

If you need to take a break, you may scroll to the end and click the Save & Continue Later button.  We look forward to our journey with you.

"*" indicates required fields

Legal Patient Name*

First Middle Initial Last

Date*

MM slash DD slash YYYY

Location

AllianceArlingtonBurlesonDallasDentonDenton SouthFort Worth - Magnolia AveFort Worth - SouthwestGainesvilleGranburyLas ColinasMansfieldMcKinneyMineral WellsPlanoSouthlakeStephenvilleWeatherford

Preferred Name*

Preferred Pronoun (Optional)

Date of Birth*

MM slash DD slash YYYY

MRN

(Leave Blank)

Sex Assigned at Birth*

Male

Female

Prefer not to answer

MEDICATIONS

Please list current medications, including non-prescription medications:

Medication
	Edit Delete
There are no Medications.

Add Medication

Maximum number of medications reached.

SUPPLEMENTS

Please list any supplements used (vitamins etc.)

Supplement
	Edit Delete
There are no Supplements.

Add Supplement

Maximum number of supplements reached.

Do you have any drug or food allergies?*

Yes

No

Drug/Food Allergies

Please list any food or drug allergies

Name of Drug/Food
	Edit Delete
There are no Allergies.

Add Allergy

Maximum number of allergies reached.

Immunizations

Flu*

Yes

No

Date (Flu)

MM slash DD slash YYYY

Pneumonia*

Yes

No

Date (Pneumonia)

MM slash DD slash YYYY

COVID*

Yes

No

Date (COVID)

MM slash DD slash YYYY

Shingles*

Yes

No

Date (Shingles)

MM slash DD slash YYYY

Have you had a CT / MRI ?*

Yes

No

Are you claustrophobic?*

Yes

No

Do you have a Dye Sensitivity?*

Yes

No

Have you ever had radiation, radium, radioactive implants or cobalt treatments?*

Yes

No

If yes, provide dates & place of treatment

Have you ever been treated for cancer?*

Yes

No

If yes, when and what type?

Have you ever had chemotherapy?*

Yes

No

If yes, what date was your last treatment?

MEDICAL HISTORY

Please check if you have or have had any of the following

Heart Disease

High Blood Pressure

Pacemaker

Seizures / Strokes

Blood Clots

Lung Disease

Kidney Disease

Thyroid

Arthritis

Osteoporosis

Diabetes

Skin Disorders

Auto-Immune DIsorder

Tuberculosis

Hepatitis B

Hepatitis C

HIV / AIDS

MRSA / C-Diff

Neurological Disease

Anxiety

Bipolar

Depression

Schizophrenia

Other Medical Conditions, Cancer, Infectious Disease, Mental Health Disorder or Implanted Medical Device

Please Describe

PAST SURGERY*

Yes

No

List surgical procedures and information below

They may include, but are not limited to: Breast (Implants, Lumpectomy, Mastectomy), Hysterectomy, Colon, Bowel, Heart, Lung & Removal of Ovaries, Appendix, Gall Bladder etc.

Type of Surgery
	Edit Delete
There are no Surgeries.

Add Surgery

Maximum number of surgeries reached.

Family History

Are you of Ashkenazi decent?*

Yes

No

Has anyone in your family had cancer?*

Biological blood relatives only

Yes

No

Unknown

How many biological siblings do you have?

Family Cancer History

List only: Grandparents, Parents, Aunts, Uncles, Siblings, Children, Grandchildren, Nieces, Nephews & half-siblings

Relative
	Edit Delete
There are no Relatives.

Add Relative

Maximum number of relatives reached.

Weight & Nutritional Status

In the last three months, have you had a weight change?*

Yes

No

Was it intentional?

Yes

No

N/A

Number of Pounds Lost

Number of Pounds Gained

Describe Your Diet*

Regular

Soft

Liquid

Diabetic

Other

Describe Your Diet (Other)

Describe Your Appetite*

Good

Fair

Poor

Cancer Screening

Date of Last Pap Smear

MM slash DD slash YYYY

Date of Last Mammogram

MM slash DD slash YYYY

Date of Last Skin Exam

MM slash DD slash YYYY

Date of Last Colonoscopy

MM slash DD slash YYYY

Date of Last Low Dose CT Chest

MM slash DD slash YYYY

MEN ONLY

Please check if you have or have had any of the following:

Chest / Breast lumps

Testicle lumps

Erectile dysfunction

Penis discharge

Testicular exam

Penis sores

Your PSA level checked

Prostate exam

Date of Your Last Prostate Exam

MM slash DD slash YYYY

WOMEN ONLY

Bone health: Have you ever had a bone density scan?

Yes

No

If yes, date of last bone density scan

MM slash DD slash YYYY

WOMEN ONLY: Menstrual Period

Age at your first period

Year

Date of your last menstrual period

MM slash DD slash YYYY

Age at menopause (your final period)

Year

Have you ever had an abnormal pap smear?

Yes

No

If yes, what treatment did you receive?

WOMEN ONLY: Pregnancy / Reproductive

Age at your first pregnancy

Age at your first delivery

Number of Pregnancies

Number of Live Births

Number of Miscarriages

Number of Abortions

Number of C-Sections

Number of Vaginal deliveries

Could you be pregnant now?

Yes

No

Unsure

Did you breast feed your children?

Yes

No

Child 1 breast fed for ___ months

Child 2 breast fed for ___ months

Child 3 breast fed for ___ months

Child 4 breast fed for ___ months

Child 5 breast fed for ___ months

Child 6 breast fed for ___ months

Have you had a tubal ligation or tubes removed?

Yes

No

If yes, date:

Has your partner/spouse had a vasectomy?

Yes

No

N/A

WOMEN ONLY: Infertility Treatments

Have you ever undergone any type of fertility treatment?

Yes

No

If yes, enter type and duration (months/years) of fertility treatment(s)

WOMEN ONLY: Breast Health

Do you perform a monthly breast self-exam?

Yes

No

If yes, how often?

Monthly

Every few months

A few times a year

Annually

Do you need help learning how to perform a breast self-exam?

Yes

No

Have you had Breast Tenderness?

Yes

No

Have you had Breast Lumps?

Yes

No

Have you had Nipple Discharge?

Yes

No

Have you had Fibrocystic disease?

Yes

No

WOMEN ONLY: Gynecologic Health

Do you currently have or have you had vaginal discharge?

Yes

No

Do you currently have or have you had Vaginal bleeding or spotting?

Yes

No

Do you or have you taken birth control pills, estrogen therapy or other hormones?

Yes

No

If yes, select one & indicate a timeframe:

Estrogen alone

Estrogen & Progesterone

Oral contraceptive pills

# of years taking Estrogen Alone

# of years taking Estrogen & Progesterone

# of years taking Oral contraceptive pills

Are you currently using them?

Yes

No

If no, date discontinued:

MM slash DD slash YYYY

How many years have you taken them?

EMPLOYMENT STATUS / HISTORY*

Employed

Unemployed

Retired

Disability

Social History

Do you now or have you ever smoked?*

Yes

No

If yes, how many years did you smoke?

If you quit, many years ago did you quit?

Please describe your current use of tobacco products:

Cigarettes

Cigar

Pipe

Vaping

Chew tobacco/Smokeless tobacco

How many cigarettes per day?

How many pipe tobacco per day?

How much vaping per day?

How much chew/smokeless tobacco per day?

Do you drink alcohol (wine, beer, liquor)?*

Yes

No

If yes, how much per day?

If yes, how much per week?

If you quit, how many years ago did you quit?

Do you use recreational drugs?*

Yes

No

Do you have a history of drug abuse?*

Yes

No

If yes, how many years did you abuse drugs?

If yes, what did you use?

If you quit, how many years ago did you quit?

Do you currently abuse drugs?*

Yes

No

If yes, what do you use?

Dental Health

Do you see a dentist regularly?*

Yes

No

If yes, what was date of last dental visit?

MM slash DD slash YYYY

Hazardous Materials Exposure

Have you ever been exposed to any hazardous materials, including by not limited to: Asbestos, Agent Orange, Heavy Metals, Pesticides and Petroleum?*

Yes

No

If yes, what was date of last exposure?

MM slash DD slash YYYY

List what you were exposed to:

Activity Level

Check all that apply to best describe your level of activity

Fully Active - can walk without aid / assistance

Somewhat Restricted- can walk with some aid / assistance and able to do light work

History of falling

Use of a cane, walker, wheelchair, motorized scooter

Out of bed and awake more than 50% of the day

Capable of all self-care

Capable of limited self-care (need help showering, dressing or eating)

Pain Assessment

Please rate your current level of pain:

0 (none)12345678910 (extreme)

How well does your medication control your pain?

100% (great)75%50%25%0% (not at all)

Distress Assessment

Please rate your average level of distress / stress over the last week:

0 (none)12345678910 (extreme)

System Review

Please check all that apply to you

GENERAL

Fever

General weakness

Skin rash / irritation

Chills

Sleep difficulties

Open sores / skin injury

Easy bruising

Swollen glands/ lymph nodes

EARS / NOSE / THROAT

Pain in ears

Hearing difficulty/deafness

Discharge from the ear

Ringing or buzzing in ears

Wear hearing aids

Sinus problems

Sores on tongue or in mouth

Dry mouth

Bleeding gums

Nose bleeds

Persistent neck stiffness

Voice changes / hoarseness

Swelling or lumps in the neck

Difficulty swallowing

EYES

Vision changes

Eye pain

Glaucoma or cataracts

Light flashes / halos

Double vision

Wear glasses or contacts

HEART / CIRCULATION

Chest pain

Unusual heartbeat

Heart defects

Legs / ankles swelling

Dizziness / fainting spells

Poor exercise tolerance

Difficulty breathing

Spitting up blood

Chronic cough

Shortness of breath

Wheezing

STOMACH / INTESTINES

Abdominal pain or cramps

Nausea / vomiting

Indigestion or heartburn

Poor or decreased appetite

Vomiting blood

Diarrhea

Blood in stools

Hemorrhoids

Constipation

Change in bowel habits

GENITAL / URINARY SYSTEM

Difficulty controlling urine

Trouble starting stream

Pain/burning with urination

Urinary frequency

Night urination

Blood in urine

Kidney stones

Sexual difficulties

MUSCLES / JOINTS

Tingling sensations / numbness

Weakness in arms or legs

Limited range of motion

Difficulty with balance

Joint problems, including pain, swelling & redness

Always thirsty

Heat or cold intolerance

Hot flashes

Night sweats

Unusually tired or sluggish

NEUROLOGIC

Severe headaches

Speech changes

Involuntary movement

Memory loss

Paralysis

Depression

Mood changes

Anxiety

Suicidal thoughts

ADDITIONAL INFORMATION:

Please indicate any health concerns that were not mentioned above.

Preferred Pharmacy

Pharmacy Name

Pharmacy Phone

Pharmacy Address

Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code

I have read this form & completed it myself

I have read this form & completed it myself

I had assistance reading & completing this form by:

I had assistance reading & completing this form by:

Name of Person Assisting You

Print Patient Name / Legally Authorized Person

Print Signature / Legally Authorized Person Signature

Save & Continue Later

While CCBD will use reasonable administrative and technical safeguards when transmitting your electronic PHI in accordance with applicable law, we also realize that there are inherent risks when communicating via email. Therefore, please be aware that by choosing to send your protected health information (PHI) and related communications via email, you are agreeing to accept the risk that your PHI may be intercepted or viewed by persons with access to your email who may not be authorized to receive such information when you consent to communication through email. CCBD will not be responsible for any privacy or security breaches outside of its control that may occur through email communications that you have consented to.