Terry L. McCaskill M.D, 6580 S McCarran Blvd, #A

Reno, NY 89509

775-826-1285

Name: _____________ Date: _______ Primary Care Dr. ________ _ Why are you seeking medical attention? _________________________ _

Allergies: ___________________________________ _

Smoking - Cig/day __ # of years __ Alcohol ___ drinks/week

Method of Contraception

Date of: Last PAP _______ _ Mammogram _____ _ Colonoscopy _____ _ DEXA (Bone Density) ____ _ Cholesterol ______ _

Have you ever used marijuana, cocaine, heroin or narcotics?□ YES ONO Have you ever been or are you currently involved in an abusive relationship? YESDJ NCO) PERSONAL HISTORY -

Normal ['.JI

01

[jl OJ rJJ

Abnormal [jJ DI [j) [J1

LP

Tuberculosis □) Rheumatic Fever tJ) Tubal Infectiong Hepatitis D) Herpes □) Chlamydia/Gonorrhea

) Pneumonia D) Genital Warts □) Bladder or Kidney infection

□) Blood TransfusiontJ)AIDS/HIV□) Other _______ _

SURGERY- Have you had an operation on any of the following: Year Year

t)) Appendix CD Tumor 0} Vagina or bladder·tJ) Gall Bladder 0) Hernia D> Laparoscopy

Year

□} Kidney Stones CD Spine □) Cesarean Sectiong Varicose Veins 0) Tonsils []} Hysteroscopy/D+C --

Hemorrhoids l"""I\ Chest Hysterectomy: LJ1 0) Ovary

t:J) Thyroid tJ) Breast 0) TubesO) Other:_________ [J) Endometrial Ablation __ D) Uterus

Have you ever been advised to have any surgical operation, which has not been done? Yes□) NoD) ILLNESSES- Have you ever had: 0) Anemia D) Hernia 0) Jaundice0) Kidney stones 0) Hayfever 0) OsteoporosisCD Arthritis 0) Cancer 0) Heart murmur0) High blood pressure□) Convulsion D) Hemorrhoids[I) Varicose veins 0) Asthma 0) Back trouble

0) Diabetes 0) Bleeding disorder0) Colitis 0) Blood clots or phlebitis0) Ulcer 0) Nervous breakdown0) Migraine 0) Abnormal pap smear□) Gall Bladder troubles

0) Other, explain; ______________________ _Have you ever been hospitalized for any illness? Yes 0) No 0) Year: ___ Diagnosis: _____________________________ _ Do you take antibiotics when you have your teeth cleaned? Yes 0) NoO} MENSTRUAL HISTORY:

Age of first period? ___ _ I have missed periods without being pregnant? Yes O No O)

Do you ever have bleeding or spotting between periods:? Yes D No D>Do you have problems with infertility? Yes IJ) No O If you are not menstruating, what age did it stop?, ___ Any bleeding or spotting since? Yes CD No D>

Do you have any other complaint, concern or question regarding sex? Yes 0) No 0)

RCi-01-1/2 (R"' 01/09)

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Typewritten Text

Male or Female Partner?

TERRY L MCCASKILL MD

ANNUAL EXAMS

Your medical office visit today is for your annual well woman exam. This appointment includes a pelvic

exam, breast exam, and a Pap smear specimen if required. Your appointment has been scheduled in a

time slot for a well woman exam only.

If you are having any other problems or issues at this time it will require more time to discuss and

evaluate. You can let your medical provider know you are having these issues and a follow up

appointment will be scheduled for you to discuss them.

*Please note: If you do have other issues that are addressed at today’s visit, your insurance will be

billed for an office visit related to this current problem and a well woman annual exam. For a problem

visit, most insurance companies require you to pay a co pay or apply the charge to your deductible

which will be your responsibility.

Patient Signature______________________________ Date___________________

REVIEW OF SYSTEMS

Terry L. McCaskill M.D. 6580 So. McCarran Blvd., #A

Reno, NV 89509

775-826-1285

Name

Date

Are you cuffently experiencing any of the following symptoms?

Constitutional: Urinary: Fever LJ Freauent urination Chills □ Urinarv uroencv

□ Sweats □ Blood in urine□ Weioht chanoe • oain or loss LJ Urinarv incontinence

Weakness LJ Gettina uo at niaht to urinate Fatiaue n Painful urination

1 Musculoskeletal: Eyes: LJ Back oain

LJ ChanQe in vision I u WeaknessLJ Joint oain stiffness, swellino

Ears Nose, Mouth, Throat:

Chanae in hearinq . lntegumentary I Breast: u Nose bleeds LJ Nodules

Sore throat u Chanae in moles, frecklesOrv mouth u Chanae in hair • orowth loss texture

u Breast lumpsCardiovascular: u Breast nioole discharae

u Dizziness u Breast oain

Shortness of breath u Chest oain Neurological I Psychiatric:

u Loss of consciousness LJ Memorv chanae u Paloitations u Depression

Anxietv Respiratory: u Mood swinas

u Chest pain LJ Numbness or tinalina u Couoh • productive or drv

Shortness of breath Endocrine:

u Wheezina LJ Excessive thirst urination u Tremor

Gastrointestinal: LJ Cold or heat intolerance

LJ Abdominal pain u Hot flashes

□ Nausea vomitina u Niaht sweats

□ Chanae in bowel habits LJ Sleep disturbances

n Chanae in appetite LJ Dark or bloodv stool u lndiaestionLJ Constipation or diarrhea

Hematologic I Lymphatic:

u Swollen lvmoh elands I

□ Easy bruisabilitv

Thank you for taking the time to answer these questions. Most insurance companies now require this

information to be updated at every visit.

RG-05-1/2

Hereditary Cancer Questionnaire

Personal Information

Patient Name: ___________________ Date of Birth: _______ Today’s Date: ________________________ Gender (M/F): ____

Healthcare Provider: ______________ Age: ______________ Reason for Visit: ______________________ Instructions: This is a screening tool for cancers that run in families. Please mark (Y) for those that apply to YOU and/or YOUR FAMILY. Next to each

statement, please list the relationship(s) to you and age of diagnosis for each cancer in your family.

You and the following close blood relatives should be considered: You, Parents, Brothers, Sisters, Sons, Daughters, Grandparents, Grandchildren,

Aunts, Uncles, Nephews, Half-Siblings, First-Cousins, Great Grandparents and Great-Grandchildren.

You and YOUR FAMILY’s Cancer History (Please be as thorough and accurate as possible)

Cancer YOU Age of

Diagnosis

PARENTS/ SIBLINGS/ CHILDREN

AGE of Diagnosis

Relatives on

MOTHERS Side

AGE of Diagnosis

Relatives on

FATHERS Side

AGE of Diagnosis

Example: BREAST CANCER

45 --- --- Aunt Cousin

45 61

Grandmother 53

Y N

BREAST CANCER (Female or Male)

Y N

OVARIAN CANCER (Peritoneal/ Fallopian)

Y N

UTERINE (Endometrial) CANCER

Y N

COLON/RECTAL CANCER

Y N

10 or more LIFETIME COLORECTAL POLYPS (Specify #)

Y N

OTHER CANCERS: Among others, consider the following cancers: Melanoma, Pancreatic, Stomach (Gastric), Prostate, Brain, Kidney, Bladder, Small Bowel, Sarcoma and Thyroid (Specify Other Cancer Types Below):

Are you of Ashkenazi Jewish descent? YES NO

Are you concerned about your personal and/or family history of cancer? YES NO

Have you or your family had genetic testing for a hereditary cancer syndrome? YES NO (Please Explain/include a copy if possible.)

Hereditary Cancer Red Flags (To be completed with your healthcare provider – Check all that apply)

Personal and/or family history of any one of the following:

MultipleA combination of cancers on the same side of the family:

2 or more: breast/ovarian/prostate/pancreatic cancer 2 or more: colorectal/endometrial/ovarian/gastric/pancreatic/other (i.e., ureter/renal pelvis, biliary tract, small bowel, brain, sebaceous, adenomas) 2 or more: melanoma/pancreatic

YoungAny 1 of the following at age 50 or Younger:

Breast Cancer Colorectal cancer Endometrial Cancer

RareAny 1 of the rare presentations at ANY AGE:

Ovarian Cancer Breast: Male breast cancer or Triple negative breast cancer Colorectal cancer with abnormal MSI/IHC, or MSI associated histology** Endometrial cancer with abnormal MSI/IHC 10 or more colorectal polyps*

** Presence of tumor infiltrating lymphocytes, Crohn’s-like lymphocytic reaction, mucinous/signet-ring differentiation, or medullary growth pattern.

* Adenomatous Type Assessment criteria are based on medical society guidelines. For individual medical society guidelines, go to www.MyriadPro.com.

Hereditary Cancer Risk Assessment Review (To be completed after discussion with your healthcare provider)

Patient’s Signature: ___________________Date: _______ Healthcare Provider’s Signature: ___________________Date:________ For Office Use Only: Patient offered hereditary cancer genetic testing? YES NO ACCEPTED DECLINED Follow-up appointment scheduled: YES NO Date of Next Appointment:_________________