Symptoms & New Patient Form Madisonhealth Cancer Care Providers New Patients Oncology Patient Resources Location & Contact Huntsman Affiliation Volunteer FAQs Forms New Patient Symptoms Symptom and New Patient Name(Required) First Last ImmunizationsEmail(Required) Enter Email Confirm Email Childhood Vaccinces Current Yes No COVID-19 Series Yes No COVID Booster Yes No Ever tested positive for COVID? Yes No If yes, enter date Flu vaccine this season Yes No Pneumonia vaccine in the last 5 years Yes No When was your last Tetanuns Vaccination? Within 5 years Greater than 5 years Patient Health Questionnaire-9 (PHQ-9)Have you fallen in the last 30 days? Yes No If yes, when? Have you traveled outside of the United States in the last 3 months? Yes No If yes, where? Do you have an Advanced Directive or any other document stating your medical wishes if you could not verbalize them? Yes No If yes, what is it? Have you ever been an employee for the Department of Energy (DOE) or Idaho National Lab (INL)? Yes No AssessmentPlease circle any symptoms of illness you are currently having today or recently. Fatigue Dizziness Visual changes Decreased hearing Memory problems Tingling or numbness Shortness of breath Sore throat Cough Edema / Swelling Chest pain Significant change in blood pressure or heart rate Appetite loss Nausea Vomiting in the last 24 hours Swallowing difficulty Mouth sores Heartburn Weight gain or loss Urinary frequency Bloody stools Diarrhea in the last 24 hours Constipation Abdominal tenderness Rash Skin problems Joint pain Hair loss Fever Cold / heat intolerance Please list any symptoms you are currently having that are not listed abovePlease list any symptoms you are currently having that are not listed above MiscellaneousOver the last 2 weeks, how often have you been bothered by any of the following problems? (select to indicate your answer) 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 1. Little interest or pleasure in doing things 0 1 2 3
