shim form - radonc.ucsf.edu patient... · the distress thermometer helps your treatment team know...

UCSF Cancer Center Patient Health Questionnaire, revised 08/04/13

Date of Birth

Patient Name

SHIM form

1. Over the past 6 months, how do you rate your confidence that you could get and keep an erection?Please choose one answer for each questions. The number in parenthesis is for scoring.

Very Low (1) Very High (5)High (4)Moderate (3)Low (2)

2. Over the past 6 months, when you had erections with sexual stimulation, how often were your erection hard enough to enter/penetrate your partner?

No Sexual Activity (0)

Almost Never or Never (1)

Almost Always or Always (5)

More than Half the Time (4)

About Half the Time (3)

Less than Half the Time (2)

3. Over the past 6 months, during sexual intercourse, how often were you able to maintain your erection after you had entered/penetrated your partner?

4. Over the past 6 months, during sexual intercourse, how difficult was it to maintain an erection to completion of intercourse?


Extremely Difficult (1) Very Difficult (2) Difficult (3) Slightly Difficult (4) Not Difficult (5)

5. During the past 6 months, when you attempted sexual intercourse, how often was it satisfactory to you?

For your information, here are descriptions of the more common Prostate Tests: Transrectal Ultra-Sound (TRUS) - A TRUS is a procedure that uses sound waves to create a video image of the prostate. It is often performed in conjunction with a prostate biopsy. A TRUS with biopsy can cost upwards of $14,000. Our staff will work with you and your insurance company to seek prior authorization. We also encourage you to contact your insurance company directly in order to verify coverage and determine what portion of the bill your insurance company will ask you to cover. If you do not have insurance and you are a self-pay patient, you are responsible for the full amount; however, we do grant all self-pay patients a 40% discount. For additional information on being a self-pay patient, we encourage you to read the section on Financial Counseling. PCA3 Urine-Sample Test - A PCA3 test is a gene-based test performed on a urine sample. This test is not currently FDA approved; therefore, some insurance companies do not cover it. We will work with you and your insurance company to seek prior authorization. We also encourage you to contact your insurance company directly in order to verify coverage and determine what portion of the bill your insurance company will ask you to cover. If you do not have insurance, or your insurance company does not cover the test, you are responsible for the full amount. The test costs approximately $450. We do grant all self-pay patients a 40% discount. For additional information on being a self-pay patient, we encourage you to read the section on Financial Counseling.













Add up your score and record it here. If your score is 21 or less, you may want to speak to your provider. Total Score

UCSF Cancer Center Patient Health Questionnaire, revised 08/04/13

Date of Birth

Patient Name

Over the past month, how often have you had a sensation of not emptying your bladder after you finished urinating? The number in parenthesis is for scoring.

Never (0) Fewer than 1 time in 5 (1)





Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?

Over the past month, how often have you stopped and started again several times when you urinated?

Over the past month, how often have you found it difficult to postpone urination?

Over the past month, how often have you had a weak urinary stream?

Over the past month, how often have you had to push or strain to begin urination?

Over the past month, how many times did you typically get up to urinate from the time you went to bed at night until the time you arose in the morning?

None (0) 1 time (1) 2 times (2) 3 times (3) 4 times (4) 5 times (5)

If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about it?

Delighted (0) Pleased (1) Mostly Satisfied (2) Mixed (3) Unhappy (4) Terrible (5)

IPSS form


























Total IPSS ScoreAdd up your score from above and record it here.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines® is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations or warranties of any kind regarding their content, use, or application, and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2013.

Instructions: First please circle the number (0-10) that bestdescribes how much distress you have been experiencing inthe past week including today.

YES NO YES NOPractical Problems

Family Problems

Emotional Problems

Spiritual/religiousconcerns

Physical ProblemsChild careHousingInsurance/financialTransportationWork/schoolTreatment decisions

Dealing with childrenDealing with partnerAbility to have childrenFamily health issues

DepressionFearsNervousnessSadnessWorryLoss of interest inusual activities

AppearanceBathing/dressingBreathingChanges in urinationConstipationDiarrheaEatingFatigueFeeling SwollenFeversGetting aroundIndigestionMemory/concentrationMouth soresNauseaNose dry/congestedPain

s/feet

SexualSkin dry/itchySleepSubstance abuseTingling in hand

Second, please indicate if any of the following has been aproblem for you in the past week including today. Be sure tocheck YES or NO for each.

Other Problems: _________________________________________

________________________________________________________

SCREENING TOOLS FOR MEASURING DISTRESS

Extreme distress

No distress

10

9

8

7

6

5

4

3

2

1

0

10

9

8

7

6

5

4

3

2

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0

NCCN Distress Thermometer for Patients

Help for distress

Distress is an unpleasant emotional state that may affect how you feel, think, and act. It can include feelings of unease, sadness, worry, anger, helplessness, guilt, and so forth. Everyone with cancer has some distress at some point of time. It is normal to feel sad, fearful, and helpless.

Feeling distressed may be a minor problem or it may be more serious. You may be so distressed that you can’t do the things you used to do. Serious or not, it is important that your treatment team knows how you feel.

The Distress Thermometer is a tool that you can use to talk to your doctors about your distress. It has a scale on which you circle your level of distress. It also asks about the parts of life in which you are having problems. The Distress Thermometer has been tested in many studies and found to work well. Please complete the Distress Thermometer and share it with your treatment team at your next visit.

The Distress Thermometer helps your treatment team know if you need supportive services. You may be referred to supportive services at your cancer center or in your community. Supportive services can include help from support groups, chaplains, social workers, counselors, and many other experts. Supportive services can also be found through the support services at right.

Support Services

National Cancer Institute’s Cancer Information ServiceTelephone 1-800-4-CANCERWebsite www.cancer.gov/aboutnci/cis/page1

Cancer Support CommunityTelephone 1- 888-793-9355Website www.cancersupportcommunity.org/MainMenu/Cancer-Support

U.S. Health Resources and Services AdministrationWebsite www.findahealthcenter.hrsa.gov/Search_HCC.aspx

U.S. Substance Abuse and Mental Health Services AdministrationWebsite www.findtreatment.samhsa.gov




Family Problems

Emotional Problems






s/feet



Other Problems: _________________________________________

________________________________________________________


Extreme distress

No distress

10

9

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2

1

0

10

9

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7

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0





Family Problems

Emotional Problems






s/feet



Other Problems: _________________________________________

________________________________________________________


Extreme distress

No distress

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2

1

0

10

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UNIT NUMBER

lJCsF Medical Center PT. NAME

BIRTH DATE

OUTPATIENT PAIN SCREENING RECORD LOCATION DATE

Have you experienced any pain within the past week? No 0 Yes 0

( If "No," stop here and give this to your provider. If "Yes," please answer the rest of the questions)

Where is your pain?

Circle a number from 0-10 that best describes how much pain you are having now.

0 1 2 3 4 5 6 7 8 9 10 No Pain Worst Pain Possible

For a child or non-English speaking adult, use Wong-Baker FACES Pain Rating Scale© or FLACC Pain Scale.

Ask the patient to circle the score that best describes how he/she feels:

Categories

FACE

LEGS

ACTIVITY

CRY

CONSOLABILITY

0 1-2 3-4 5-6 7-8 No Hurt Hurts Little Bit Hurts Little More Hurts Even More Hurts Whole Lot

FLACC PAIN SCALE

0

No particular expression or smile.

Normal position or relaxed.

Lying quietly, normal position, moves easily .

No cry (awake or asleep).

Content, relaxed.

Scoring

1

Occasional grimace or frown, withdrawn, disinterested.

Uneasy, restless, tense.

Squirming, shifting back and forth, tense.

Moans or whimpers; occasional complaint.

Reassured by occasional touching, hugging, or being talked to - distractible.

9-10 Hurts Worst

2

Frequent to constant quivering chin; clenched jaw.

Kicking, or legs drawn up.

Arched, rigid or jerking.

Crying steadily, screams or sobs - frequent complaints.

Difficulty to console or comfort.

<3 What does your pain feel like? Circle response: sharp dull burning aching throbbing tender numb 0 w ~ stabbing gnawing shooting exhausting penetrating miserable unbearable continuous occasional <( z <3 a: 0 Ql What makes the pain better? _______________________________ _ 0 ~ What makes the pain worse? ______________________________ _ 0 ~ Are you currently taking medication(s) or using some type of treatment for pain relief? m NoD Yes D ~ o If yes, list medication and/or treatment: ___________________________ ~ ~ [£ U") !'-

~ PatientorCareg~erSignature ______________________ ~Date t'-

t'- ~------------------------------------------------------------------------------------~ "'wong, DL: Whaley and Wong·s Nursing Care of Infants and Children, 6th ed.

St. Louis, MO Mosby 1999. used with permission OUTPATIENT PAIN SCREENING RECORD

williamlin

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williamlin

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Patient Name:

Date of Birth:

Cancer Treatment History

1. Have you ever received treatment with radiation therapy in the past?

YES NO skip next question

2. If YES, please provide the following information:

Type of Cancer Name of Facility/Hospital Name of Radiation Oncologist Phone Number (if known)

3. Have you ever received treatment for cancer with chemo/hormonal therapy in the past?

YES NO skip next question

4. If YES, please provide the following information:

Type of Cancer Name of Facility/Hospital Name of Oncologist Phone Number (if known)

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lJCsF Medical Center

UCSF Benioff Children's Hospital

NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT OF RECEIPT

UNIT NUMBER

PT. NAME

BIRTHDATE

LOCATION DATE

The UCSF Notice of Privacy Practice provides information about how we may use and disclose protected health information about you.

In addition to the copy we have provided you, copies of the current notice are available by accessing our website at http://www.ucsfhealth.org and may be obtained throughout UCSF Health System.

I acknowledge that I have received the Notice of Privacy Practice.

__ ! ! __ Signature of Patient or Patient's Representative Date

Print Name Relationship to Patient

~ Name of Interpreter (if applicable) w 0: (j)

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~ If written acknowledgement is not obtained, please check reason: 0: 0 1-z ~ D Notice of Privacy Practice Given - Patient Unable to Sign c... I

~ D Notice of Privacy Practice Given - Patient Declined to Sign _J

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0 0: 0 (..)

DOther ________________________________________ __

~ ........••............•..•.............••..............•................................................••.••.............•••...... _J <( (..)

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~ Signature of UCSF Representative

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Print Name

__ ! ! __ Date

Department

00 ~----------------------------------------------------------------------·--~ NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT OF RECEIPT

williamlin

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williamlin

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I authorize _______________________

x_

_______(Name of person or facility which has information - example: UCSF/Mt. Zion)

to release health information to:___UCSF Medical Center: Cancer Center_____

Name of person or facility to receive healthinformation (full address)

_______________________________________Street address:

_______________________________________City, State, Zip Code

_______________________________________

Please specify the health information you authorize to be released:

Type(s) of health information: __________________________________________

Date(s) of treatment: _________________________________________________

The following information will not be released unless you specificallyauthorize it by marking the relevant box(es) below:

� Information pertaining to drug and alcohol abuse, diagnosis or treatment (42C.F.R. §§2.34 and 2.35).

� Information pertaining to mental health diagnosis or treatment (Welfare andInstitutions Code §§5328, et seq.)

� Release of HIV/AIDS test results (Health and Safety Code §120980(g)).

� Release of genetic testing information (Health and Safety Code §124980(j)).

EXPIRATION OF AUTHORIZATIONUnless otherwise revoked, this Authorization expires ____________(insertapplicable date or event). If no date is indicated, the Authorization willexpire 12 months after the date of my signing this form.

Print Name Signature (Patient, Parent, Guardian)

Date Time Relationship to Patient (Parent,Guardian, Conservator, PatientRepresentative)

Requested format: � Paper � CD

DATE:

PATIENT NAME:

BIRTHDATE:

ID VERIFICATION (TYPE):

ID VERIFIED BY:

AUTHORIZATION FOR RELEASEOF HEALTH INFORMATION

AUTHORIZATION FOR RELEASEOF HEALTH INFORMATION

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The purpose of this release isfor (check one or more):

� Continuity of care ordischarge planning

� Billing and payment of bill

� At the request of the patient/patient representative

� Other (state reason)_______

_________________________

_________________________

(1)

(2)

(3)

(4)

NOTICEUCSF and many other organizations and individuals such as physicians,hospitals and health plans are required by law to keep your healthinformation confidential. If you have authorized the disclosure of yourhealth information to someone who is not legally required to keep itconfidential, it may no longer be protected by state or federalconfidentiality laws.

YOUR RIGHTSThis Authorization to release health information is voluntary. Treatment,payment, enrollment or eligibility for benefits may not be conditioned onsigning this Authorization except in the following cases: (1) to conductresearch-related treatment, (2) to obtain information in connection witheligibility or enrollment in a health plan, (3) to determine an entity’sobligation to pay a claim, or (4) to create health information to provide toa third party.

This Authorization may be revoked at any time. The revocation must be inwriting, signed by you or your patient representative, and delivered to:Health Information Management Services, UCSF Medical Center, 400Parnassus Ave., Room A68, San Francisco, CA 94143-0308. Therevocation will take effect when UCSF receives it, except to the extentUCSF or others have already relied on it.

You are entitled to receive a copy of this Authorization.

shim form - radonc.ucsf.edu patient... · the distress thermometer helps your treatment team know...

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