Welcome to Ventura County Radiation Oncology Medical Group (VCROMG).
Please provide us with a list of your physician team followed by a few questions specific to our office.
Physician Name: Phone No: Area Code Phone Number
Primary Care: Phone No: Area Code Phone Number
Medical Oncologist: Phone No: Area Code Phone Number
Surgeon: Phone No: Area Code Phone Number
Other: Phone No: Area Code Phone Number
Have you had prior radiation therapy? No If yes, what part of the body was treated blank
Location of Facility/Treating Physician blank
Has a family member or friend ever been treated by Dr. O’Connor or Dr. Montes?Yes No
If yes, please list their name(s):blank
Do you have a pacemaker or ICD (defibrillator)? Yes No If yes, date last checked blankPlease bring your cardiac device card with you to your appointment.
Do you have an Advance Directive? Durable Power of Attorney Living Will or DNR
Name of person assigned blank Phone Area Code Phone Number
PREVIOUS CHEMOTHERAPY? Yes No
PRESENT OR PLANNED TREATMENTS IN FUTURE? Yes No
If YES: Name of Drug: blanks Date of Last Treatment: blank
CONSENT FOR E-PRESCRIBING & OBTAINING MEDICATION HISTORY I understand that as a part of my electronic health record, VCROMG will transmit my prescriptions electronically as permitted, to the pharmacy that I designate as my primary pharmacy provider. Additionally, VCROMG will obtain the history of my prescriptions from pharmacy benefit managers and I understand that those prescriptions will become a part of my electronic health record. By signing below I hereby give consent to the above actions.
Other Illnesses Not Listed:?
Have you had a colonoscopy? Yes No and if so when
Age at first menstruation Frequency of cycle (every so many days) Date of last menses Possibility you are or may be pregnant? Yes No Age at first pregnancy Number of pregnancies Number of live births Breast fed? Yes No Age at start of menopause Have you used estrogen supplementation? Yes No Recent mammogram Date Recent bone density scan Date
Occupation Retired Yes No
Family/Friend support person
Do you live alone, with spouse or with another family member? Please specify:
Do you or have you ever smoked cigarettes? Yes No Current everyday smoker? How much? Former smoker? How much? Date quit Other tobacco Products Yes No
Do you drink alcohol? Yes No How much?
Do you have a history of illicit drug use? Yes No If yes, approximately when
Do you currently have? (If yes, check appropriate boxes)
Pain Scale 0-100-10 Location. location
Have you received a Influenza (flu) vaccine? Yes Date No Personal reasons Medical reasons
Have you received Pneumonia vaccine? Yes Date No Personal reasons Medical reasons
¿Tiene usted actualmente? (Si la respuesta es sí, marque las casillas apropiadas)
Escala de dolor 0-100-10 Ubicación location
HISTORIAL DE VACUNACIÓN
¿Ha recibido una vacuna contra la influenza (gripe)?Type option 1 FechaDate Type option 1 Por razones personales Personal Por razones médicas Medical
¿Ha recibido la vacuna contra la neumonía?Type option 1 FechaDate Type option 1 Por razones personales Personal Por razones médicas Medical
By signing this form,
I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices.
I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures.
I understand that I can be charged the additional fees that my insurance does not cover.
I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis.