Spotting Cancer Survey Questions
|
|
- Bruce Hopkins
- 5 years ago
- Views:
Transcription
1 Q1a. Please indicate to what extent you agree or disagree with the following statement. Knowing the major signs and symptoms for cancer can help to detect the disease. 1 Disagree completely 5 Agree completely Q1b. Please indicate to what extent you agree or disagree with the following statement. Early detection of cancer improves survival rates. 1 Disagree completely 5 Agree completely Q. Please list the warning signs and symptoms of cancer you are aware of. This could be for any type of cancer. Q. Which of the following warning signs and symptoms of cancer are you aware of? Please select all that apply, including those you mentioned previously Weight loss Bowel changes Fatigue - Continuous Lumps - neck, armpit, breast, etc. White spots or patches in mouth Persistent cough Pain/ache in joints Bloating Low grade temperature for days Persistent headache - even after taking medicine Sweating at night Fingernail changes Repeat infections Falling Down Indigestion Itching in same area Bleeding - unscheduled or uncommon Skin and/or mole changes in color, shape, and size Q. If you were more aware of the most common signs and symptoms for cancer, how likely would you be to develop a plan to routinely check for them? Page 1 of 6
2 Please select one Definitely would develop a plan Probably would develop a plan Probably would not develop a plan Definitely would not develop a plan Don t know I already have an action plan Q5. Approximately how often do you do self-examination for cancer signs and symptoms? Never Less than once a year Once a year - times a year Once every months Once every months Once a month More than once a month Q6. What methods do you use to check your body for cancer signs and symptoms? Please select all that apply Routine doctor visit Self-examination Medical testing/screening Screening products bought at a store Partner helps me check Personal care assistant Other Q7. If you had a sign or symptom that you thought might be a sign of cancer, how likely would you be to contact a medical professional? Please select one Definitely would contact a medical professional Probably would contact a medical professional Might or might not contact a medical professional Probably would not contact a medical professional Definitely would not contact a medical professional Q8. How soon would you contact a medical professional after having a sign or symptom that you thought might be cancer? Please select one Within hours Within 1 week Within weeks Within 1 month Within months Within 6 months Page of 6
3 Within a year Not sure how long Q9. Which of the following are potential reasons that might prevent you from seeing a doctor or a medical professional? Please select all that apply Do not have a doctor Do not know which of my doctors to call Do not have enough money to pay for the doctor s visit Do not have insurance coverage Do not want to pay for an appointment I would be worried about the doctor thinking that I am overreacting My doctor would be difficult to talk to It is difficult to make an appointment I am too busy to make time to go the doctor I have too many other things to worry about It would be difficult to arrange transportation to the doctor I would be worried about what the doctor might find I would not feel confident talking about my symptom(s) with the doctor Other Q10. What medical testing and screening methods are available to help detect cancer (or cancer related) signs and symptoms? a. b. c. d. e. f. g. h. I do not know any Q11. Which of the following medical testing and screening methods that are available to help detect cancer (or cancer related) signs and symptoms are you aware of? Please select all that apply, including those you mentioned previously. Mammogram Colonoscopy Blood test Pap smear MRI Ultrasound Chest x-ray CAT Scan PET Scan Oral/ Mouth check by Dentist Skin scan by Dermatologist Doctor office check up Urine test Stool test Page of 6
4 Prostate Check Biopsy Genetic/Evaluation Q1. Which of the following medical testing and screening methods have been used on you? Please select all that apply. Mammogram Colonoscopy Blood test Pap smear MRI Ultrasound Chest x-ray CAT Scan PET Scan Oral/ Mouth check by Dentist Skin scan by Dermatologist Doctor office check up Urine test Stool test Prostate Check Biopsy Genetic/Evaluation Q1. What products that can be bought at a store, or online, can be used to help detect cancer (or cancer related) signs and symptoms? a. b. c. d. e. f. g. h. I do not know any Q1. Which of the following products that can be bought at a store, or online, to help detect cancer (or cancer related) signs and symptoms are you aware of? Please select all that apply, including those you mentioned previously. Accu-Cervical cancer test PSA testing by Home Health AMAS cancer test HCG cancer test kit EZ Detect EarlyCDT - Lung test MeasureBowel Health Page of 6
5 I don t know Q15. Which of the following products that can be bought at a store, or online, have you used? Please select all that apply. [PROG: PIPE IN RESPONDENT S ANSWERS FROM Q1] Q16. How interested would you be in using each of the following to find information about cancer signs and symptoms? 1 Not at all interested 5 Extremely interested A website dedicated to signs and symptoms cancer An online search engine (Google, Bing, etc.) Blogs Online videos Podcasts Social Media (Facebook, Twitter, etc.) Books Magazines or health journals Doctor or other healthcare professional Friends or family members Q16a. How interested would you be in using each of the following to find information about how to do self-examination for cancer? 1 Not at all interested 5 Extremely interested A website dedicated to how to do self-examination for cancer An online search engine (Google, Bing, etc.) Blogs Online videos Podcasts Social Media (Facebook, Twitter, etc.) Books Magazines or health journals Doctor or other healthcare professional Friends or family members Page 5 of 6
6 Q17. Which of the following describes you? Yes No Current or former student of biology or medical-related field Currently or previously worked in a healthcare-related position Q18. From the following list, please indicate who currently, or previously, had been diagnosed with cancer. Please select all that apply Yourself Your spouse/partner/significant other Grandparent Parent Child Friend Prefer not to answer [PROG: IF Q18 = PREFER NOT TO ANSWER, SKIP Q19] Q19. For the people who currently, or previously, had been diagnosed with cancer, how was the cancer first detected? [PROG: SHOW THOSE SELECTED FROM PREVIOUS QUESTION] Select one response Routine doctor visit Self-examination Medical testing/screening Screening products bought at a store Partner detected it Personal care assistant Other: Not sure Page 6 of 6
SIGNS, SYMPTOMS AND SCREENING GUIDELINES
SIGNS, SYMPTOMS AND SCREENING GUIDELINES SIGNS AND SYMPTOMS You may think it s normal, but it could be a sign or symptom of an illness or cancer-related disease. If you are experiencing any of these signs
More informationHealth History. Tests and Procedures: Test: Date: Location: Provider: Abnormal: Results/Notes: Monthly self breast exam. Last mammogram (female)
Comprehensive Cancer Center A Cancer Center Designated by the National Cancer Institute Please answer the following questions and bring this form to your first appointment at Rutgers Cancer Institute of
More informationYou can also complete the survey over the phone with a trained interviewer by calling the study team toll free at
Last modified: 0//08 0:0:5 AM Thank you very much for your participation in this important study. If you prefer, you can complete this survey online at www.stjude.org/ltfu-ask8. Your log-in ID is your
More informationTake Care of Yourself Your friends and family need you!
Take Care of Yourself Your friends and family need you! Cancer Facts * Cancer is a disease in which cells of the body grow out of control. * Cancer is often named for where it starts in the body. * We
More informationWelcome to the UCLA Center for East- West Medicine Primary Care
Instructions: Welcome to the UCLA Center for East- West Medicine Primary Care We ask a lot of questions because we really want to get to know you! Please take your time with the paper work and return it
More informationCOMPREHENSIVE NEW PATIENT QUESTIONNAIRE
What brings you in today? What do you prefer to be called (nickname)? Please list all of your medical conditions. 1. 5. 2. 6. 3. 7. 4. 8. What surgical or medical procedures have you had in the past? 1.
More informationA. Please include any medications (herbal, prescription, or Over-the-counter) and any supplements that you are currently taking.
New Patient Questionnaire Please complete this and bring it with you to your visit. If you have it completed five days or more prior to your visit, please mail or fax it to our office. Most recent treating
More informationCancer , The Patient Education Institute, Inc. ocf80101 Last reviewed: 06/08/2016 1
Cancer Introduction Cancer begins in your cells, which are the building blocks of your body. Extra cells can form a mass called a tumor. Some tumors aren t cancerous, while other ones are. Cells from cancerous
More informationName: Today s Date: Address: State, Zip Code
New Patient Health History Questionnaire Name: Today s Date: Address: City State, Zip Code Email Address: Date of Birth: Home Telephone #: Cell Number: Work Number: Emergency Contact name & number: Referred
More informationCancer. University of Illinois at Chicago College of Nursing
Cancer University of Illinois at Chicago College of Nursing 1 Learning Objectives Upon completion of this session, participants will be better able to: 1. Develop a basic understanding of cancer 2. Describe
More informationUW MEDICINE REGIONAL HEART CENTER HEART TRANSPLANT. Orientation Class at University of Washington Medical Center
UW MEDICINE REGIONAL HEART CENTER HEART TRANSPLANT Orientation Class at University of Washington Medical Center OVERVIEW This slideshow explains: Your Transplant Evaluation Transplant Listing Heart Transplant
More informationNew Patient Information Form
New Patient Information Form Patient Label Dear Patient: Please take a few minutes to complete this form. Your answers will help the doctors and staff plan and provide your care. If you are unsure of any
More informationGuidelines for the Early Detection of Cancer
Guidelines for the Early Detection of Cancer The American Cancer Society recommends these cancer screening guidelines for most adults. Screening tests are used to find cancer before a person has any symptoms.
More informationJohns Hopkins Hospital Division of Gastroenterology Patient Questionnaire
Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire Please complete this questionnaire before your scheduled appointment and bring this form with you the day of your visit. Patient
More informationTo insure that your physical examination is of the highest quality and comfort, please observe the following:
Dear Patient: To insure that your physical examination is of the highest quality and comfort, please observe the following: PHYSICAL EXAM NOTES Please bring the Physical Exam forms completely filled out
More informationCancer Research UK Tesco Charity of the Year Spotting the signs of cancer For men
Cancer Research UK Tesco Charity of the Year 2012 Spotting the signs of cancer For men Thousands of people beat cancer every year. When cancer is diagnosed at an early stage, treatment is often simpler
More informationPRE-VISIT QUESTIONNAIRE FOR NEW PATIENTS
UF Health Senior Care PO Box 100383 Gainesville, FL 32608 352-265-0615 Fax 352-294-5803 PRE-VISIT QUESTIONNAIRE FOR NEW PATIENTS Please complete this questionnaire at home and bring it with you to the
More informationOther doctors to receive copies of records : Chief complaint / history of present illness (Describe why you have been referred here):
Patient Name: Date: Age: Date of Birth: Preferred Name: Preferred Language: Address: City: State: Zip: Phone: Cell Phone: Preferred Phone: Emergency Contact: Relationship: Email: If you would like to opt
More informationCancer Facts for Women
Cancer Facts for Women Some of the cancers that most often affect women are breast, colorectal, endometrial, lung, cervical, skin, and ovarian cancers. Knowing about these cancers and what you can do to
More informationNo. 2 - Persistent Pain or Discomfort in Any Body Area
See Your Doctor When Symptoms Occur, and Get Regular Checkups. Experts say that men could benefit greatly by being alert to certain cancer symptoms that indicate a trip to the doctor's office sooner rather
More informationName : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Address: May we leave a
Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Email Address: May we leave a message? Home Work Cell PLEASE DO NOT LEAVE A MESSAGE Marital
More informationLeader Lesson Family and Consumer Education (FCE) Breast & Cervical Cancer Teaming Up and Taking Control!
Leader Lesson Family and Consumer Education (FCE) Breast & Cervical Cancer Teaming Up and Taking Control! Goal Protect the health and well-being of FCE members by teaching cancer prevention techniques
More informationMEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
More informationknow how often they should get checked for breast cancer?
Section 1 Breast Health Perspectives: These questions ask about general points of view on common breast health practices. 1.1. What do you think is the right age for people to start getting clinical breast
More informationPatient Information Leaflet Number: CC 041 v2
Be Cancer Aware Patient Information Leaflet Number: CC 041 v2 Increase your awareness The sooner cancer is diagnosed the easier it can be treated. Being aware of when to seek advice can make a difference.
More informationNew Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
More informationBe cancer aware Patient Information
Be cancer aware Patient Information Author ID: AMK Leaflet Number: CC 041 Version: 2 Name of Leaflet: Be cancer aware Be Date cancer Produced: aware October 2017 Page 1 of 12 Review Date: October 2019
More informationLung cancer. easy read
Lung cancer easy read About this easy read booklet This booklet is about lung cancer. You can find out what lung cancer is and how it is treated. If you are worried about lung cancer, there are lots of
More informationThis information explains the advice about suspected cancer that is set out in NICE guideline NG12.
Recognising, investigating and referring people with symptoms of suspected cancer Information for the public Published: 25 June 2015 nice.org.uk About this information NICE guidelines provide advice on
More informationColumbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, www.coainc.cc Ph: 614.442.3130, Fax: 614.442.3145 Name (Last, First, Middle) Birth Date Age Social Security # Appointment
More informationLUNGS? YOU GET THESE YOUR GUIDE TO YEARLY LUNG CANCER SCREENING CHECKED REGULARLY. WHAT ABOUT YOUR. Think. Screen. Know.
YOU GET THESE CHECKED REGULARLY. WHAT ABOUT YOUR LUNGS? YOUR GUIDE TO YEARLY LUNG CANCER SCREENING WHAT YOU SHOULD KNOW BEFORE, DURING, AND AFTER Think. Screen. Know. Talk to your doctor. TABLE OF CONTENTS
More informationTOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES Medical Complex Drive, Suite 6 Tomball, TX
TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES 13414 Medical Complex Drive, Suite 6 Tomball, TX 77375 281-516-0212 Welcome! We are glad that you have chosen Tomball Regional Internal Medicine Associates
More informationNew Patient Specialty Intake Form Department of Surgery
This form contains questions specific to the Department of Surgery. If you are new to Baylor College of Medicine and have not been seen in any of our offices, please be sure to complete our New Patient
More informationBreast Cancer Screening Navigation Script
Breast Cancer Screening Navigation Script This document supports your conversations with breast cancer screening candidates. Development of the navigation script is based on field research, conducted with
More informationCancer Facts for People Over 50
National Institute on Aging AgePage Cancer Facts for People Over 50 Cancer strikes people of all ages, but you are more likely to get cancer as you get older, even if no one in your family has ever had
More informationMEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
Smoking history Alcohol history Never Quit Never Quit PART 2 - MEDICAL HISTORY Date of last colonoscopy? Date of last mammogram? Date of last pap smear? Date of last flu vaccine? Date of last pneumonia
More information(Patients complete on initial consult)
Person Completing the Form: Primary Care Physician and phone number: Referring Physician and phone number: Please list all other physicians involved in your care: Current Medical History: What is the health
More informationPhilippine Cancer Society Forum: Cancer can be cured!
Philippine Cancer Society Forum: Cancer can be cured! Throughout history, doctors and scientists have extensively studied Their researchers have not only yielded a wealth of information on the disease,
More informationIntegrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
More informationCancer Facts for Men FOR REVIEW ONLY
Cancer Facts for Men Prostate cancer The chance of getting prostate cancer goes up as a man gets older. Most prostate cancers are found in men over the age of 65. For reasons that are still unknown, African
More informationScreening tests. When you need them and when you don t
Screening tests When you need them and when you don t S creening tests help doctors look for diseases when you don t have symptoms. The tests can Screenings find problems early, when they are easier to
More informationCancer is the single name assigned to more than 100 diseases that can occur in any part of body
Cancer is the single name assigned to more than 100 diseases that can occur in any part of body It s actually the result of abnormal cells that multiply and spread out of control, damaging healthy cells
More informationReferral guidelines for suspected cancer
Referral guidelines for suspected cancer Understanding NICE guidance information for people who may need a referral, their families and carers, and the public Prepared for second consultation The paragraphs
More informationMEDICAL QUESTIONNAIRE (female)
MEDICAL QUESTIONNAIRE (female) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501 The appointment comprises of a discussion about this questionnaire and a subsequent medical examination.
More informationCANCER. Mrs. Davis Health Education
CANCER Mrs. Davis Health Education Cancer Terms: Tumors: Masses of useless tissue Benign: Non-cancerous Malignant: Cancerous Metastasis: Spread of cancer from the point where it originated to other parts
More informationAnnual Exam Review. Medications: Medication Strength (mg) Directions ( how many pills and how many times a day)
Annual Exam Review Name Medications: Medication Strength (mg) Directions ( how many pills and how many times a day) Overall health: Good Fair Poor Men : When was the last time you had: Prostate exam Prostate
More informationWelcome to the Kentucky Neuroscience Institute at the University of Kentucky!
Welcome to the Kentucky Neuroscience Institute at the University of Kentucky! The Kentucky Neuroscience Institute is on the first floor of the Kentucky Clinic. The address is 740 South Limestone Street,
More informationCapital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
More informationName: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).
Name: Date: Referring Provider: Age: D.O.B. Race/ ethnicity: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). We are interested in learning
More informationCreve Coeur Family Medicine, LLC
Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal
More informationHow is primary breast cancer treated? This booklet is for anyone who has primary breast cancer and wants to know more about how it is treated.
How is primary breast cancer treated? This booklet is for anyone who has primary breast cancer and wants to know more about how it is treated. How is primary breast cancer treated? Part 1 the treatment
More informationA patient s guide to understanding. Cancer. Screening
A patient s guide to understanding Cancer Screening Contents 04 06 10 12 Cancer Screening Who Should Go For Cancer Screening 05 Nasopharyngeal Carcinoma Colorectal Cancer 08 Lung Cancer Liver Cancer Breast
More informationPATIENT INJURY/MEDICAL HISTORY FORM
PATIENT INJURY/MEDICAL HISTORY FORM Name Date Date of Loss/Onset (Accident): Claim Number: _ Describe Accident: Specifics of Accident (Mark each that applies to the accident): Job or Work Related injury
More informationPATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
More informationMEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
More informationWellness Along the Cancer Journey: Healthy Habits and Cancer Screening Revised October 2015 Chapter 7: Cancer Screening and Early Detection of Cancer
Wellness Along the Cancer Journey: Healthy Habits and Cancer Screening Revised October 2015 Chapter 7: Cancer Screening and Early Detection of Cancer Healthy Habits and Cancer Screening Rev 10.20.15 Page
More informationAllan Warshowsky MD,FACOG, ABIHM. New Patient Questionnaire Date of appointment :
New Patient Questionnaire Date of appointment : Name: Address: Apt# City: State: Zip: Phone: Cell: Email: Age: DOB: Referred By: Your occupation: Allergies: To Medications: Other: Reason for Today s Visit:
More informationNew Adult Intake Form
New Adult Intake Form Please complete the following form in order to provide us with the background information we require to ensure you receive comprehensive care. Name: Today s Date: Age: Date of Birth
More informationPATIENT HEALTH HISTORY
DEMOGRAPHICS Name: Date of Birth: Sex: Male Female Ethnicity (optional): Hispanic or Latino Not Hispanic or Latino Race (optional): White Black or African American Other: PREFERRED LANGUAGE Is English
More informationBreast and Ovarian Cancer
Patient Education Breast and Ovarian Cancer Screening and detection The goal of screening for cancer is to find it as early as possible, when it is easiest to cure. This handout describes the symptoms
More informationScottsdale Family Health
Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give
More informationBreast Cancer Follow-Up Appointments with Your Family Doctor
Breast Cancer Follow-Up Appointments with Your Family Doctor Information for breast cancer patients who have finished treatment UHN Read this resource to learn about: What is follow-up care How often you
More informationWho to call? Your guide to health care in Lothian
Who to call? Your guide to health care in Lothian This booklet tells you how to get the right healthcare, at the right time, in the right place. What s in this book Looking after yourself 1 Pharmacy (chemist)
More informationJennifer Teitelbaum Palmer M.D Keswick Road Suite 100 Baltimore MD 21211
PERSONAL INFORMATION - Please fill out this form as completely as you can. Please print your answers. Today s Date First Last Birthdate Social Security Number Ethnic Identity Gender Identity Marital Status
More informationMedical Diagnostic Associates, P.A.
Medical Diagnostic Associates, P.A. Carol G. Simon Cancer Center at Overlook Hospital 99 Beauvoir Ave, Summit, NJ 07901 Phone (908) 608-0078 Fax (908) 608-1504 Dennis A. Lowenthal, M.D., Daniel J. Moriarty,
More informationDate of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:
Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
More informationPremier Internal Medicine of Alpharetta, PC
Patient Information Date / / First Name Middle Initial Last Name Date of Birth / / Social Security # Gender Male Female Marital Status Single Married Separated Divorced Widowed Address Apt # City State
More informationMargie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
More informationLISTEN A MINUTE.com. Senility. Focus on new words, grammar and pronunciation in this short text.
LISTEN A MINUTE.com Senility http://www.listenaminute.com/s/senility.html One minute a day is all you need to improve your listening skills. Focus on new words, grammar and pronunciation in this short
More informationDiagnosis of cancer in the UK, and how it might change in future
Diagnosis of cancer in the UK, and how it might change in future The UK has one of the poorest survival rates of cancer in Western Europe. Treatment given in UK NHS hospitals is possibly among the best
More informationGIDEON G. LEWIS, M.D.
GIDEON G. LEWIS, M.D. Date: LAST Name: FIRST Name: MIDDLE Initial: Address: City: State: Zip Code: Date of birth: / / Social Security #: - - Sex: M F Marital Status (Circle): Single Married Divorced Widowed
More informationPATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
More informationPATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
More informationPlease answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
More informationYou can only get this drug through the Natpara REMS Program.
PATIENT & CAREGIVER EDUCATION Parathyroid Hormone Brand Names: US Natpara Warning This drug has been shown to raise the chance of bone tumors in lab animals. It is not known if there is a higher chance
More informationName. Date of Birth. Primary Care Doctor? Who is the Doctor that referred you to us? Name of person completing this form?
Orthopaedic Surgical Oncology of Arizona Dr Bruce A Mallin Dr Matthew J Seidel PATIENT HISTORY FORM To help us better understand your risk factors for cancer, please complete this medical history. Please
More informationAdult Health History New Patient
Adult Health History New Patient Today s Date PREFERRED NAME DATE OF BIRTH Reason for visit: What are your health goals for the next year? Previous Primary care Provider? Last visit? Specialists (Past
More informationScreening Mammograms: Questions and Answers
CANCER FACTS N a t i o n a l C a n c e r I n s t i t u t e N a t i o n a l I n s t i t u t e s o f H e a l t h D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s Screening Mammograms:
More informationguide to living with cancer Brought to you by Alliance Health.
guide to living with cancer Brought to you by Alliance Health. The content in this guide is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice
More informationInformation for Patients Receiving Radiation Therapy: External Beam Treatment for Prostate Cancer
Patient & Family Guide 2018 Information for Patients Receiving Radiation Therapy: External Beam Treatment for Prostate Cancer www.nscancercare.ca Information for Patients Receiving Radiation Therapy: External
More informationPATIENT INFORMATION. Name: First Name MI Last Name. Date of Birth: / / Sex: Male / Female / Declined SSN:
PATIENT INFORMATION Name: First Name MI Last Name Date of Birth: / / Sex: Male / Female / Declined SSN: Race: Ethnicity: Hispanic/Latino Not Hispanic/Latino Declined Marital Status: Single Married Divorced/Separated
More informationWhat is cancer? l Cancer is a group of several diseases caused by the abnormal growth of cells.
Cancer Biology What is cancer? l Cancer is a group of several diseases caused by the abnormal growth of cells. What is cancer? l Cancer is a group of several diseases caused by the abnormal growth of cells.
More informationKaiser Permanente 2012 Sample Fee List Members in any deductible plan 1 can use this list to help estimate their charges.
Kaiser Permanente 2012 Sample Fee List Members in any deductible plan 1 can use this list to help estimate their charges. NORTHERN CALIFORNIA As your partner in health, we want to help you manage your
More informationProvidence Medical Group
Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
More information*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
More informationLymphoma, skin cancer, and other types of cancer have happened in people treated with this drug. Talk with your doctor.
PATIENT & CAREGIVER EDUCATION Baricitinib Brand Names: US Olumiant Warning Severe infections like tuberculosis, shing les, fung al infections and other bacterial or viral infections have happened in patients
More informationPATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: Gender: SSN: Race: Marital Status: Address Line: City: State: Zip Code: Home Phone: Work Phone: Email Address: Cell Phone: Primary Care
More informationSingle Suspected Cancer Pathway Definitions pathway start date
Single Suspected Cancer Pathway Definitions pathway start date Date: March 2018 Version: 1.2.1 Wales Cancer Owner: Network and Welsh Government Status Published 1 P a g e Purpose of Document This document
More informationPatient: Age: Date: Height Weight Alternative Telephone number: Occupation: Do you have a living will or advance directive? YES NO
, M.D., Jennifer Halpern, M.D. Orthopaedic Oncology Patient Questionnaire Initial Evaluation Patient: Age: Date: Height Weight Alternative Telephone number: Occupation: Do you have a living will or advance
More informationThis information explains the advice about familial breast cancer (breast cancer in the family) that is set out in NICE guideline CG164.
Familial breast cancer (breast cancer in the family) Information for the public Published: 1 June 2013 nice.org.uk About this information NICE guidelines provide advice on the care and support that should
More informationMarcelo Garzon HOM.DSHomMed.Bsc. (Please be certain that all in take forms are completed and returned on time)
Marcelo Garzon HOM.DSHomMed.Bsc. www.sagehomeopathy.ca (Please be certain that all in take forms are completed and returned on time) NAME: Personal Health History DATE: OHIP # D.O.B : AGE: PHONE: MAY WE
More informationWALNUT CREEK FAMILY PRACTICE 4303 JODECO ROAD MCDONOUGH, GA
WALNUT CREEK FAMILY PRACTICE 4303 JODECO ROAD MCDONOUGH, GA 30253 770-898-7840 Dear Walnut Creek Family Practice Patient, Your physical appointment is scheduled for you and no one else at that time. If
More informationPlease complete and return to the office prior to your appointment.
Please complete and return to the office prior to your appointment. Name: Last:, Today s Date: First: MI: Nickname: Date of Birth: Age: Sex: M F SSN: Parent/Legal Guardian (if the patient is a minor):
More informationStep One: The Referral
Step One: The Referral There are 3 phases of your journey through kidney transplant. They are: 1. Referral and Evaluation 2. Wait List 3. Post-Kidney Transplant In this section, you will find information
More informationPatient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
More informationHealth and Fitness A Matter of Stewardship
Health and Fitness A Matter of Stewardship Panel Or do you not know that your body is a temple of the Holy Spirit who is in you, whom you have from God, and that you are not your own? For you have been
More informationBREAST CANCER & CERVICAL CANCER SCREENING
BREAST CANCER & CERVICAL CANCER 1 BREAST Cancer WHAT IS BREAST CANCER? Breast cancer starts when cells in the breast begin to grow in an uncontrolled way and build up to form a lump (also known as a tumour).
More informationNorthumbria Healthcare NHS Foundation Trust. Your guide to discharge from the breast clinic. Issued by the Breast Team
Northumbria Healthcare NHS Foundation Trust Your guide to discharge from the breast clinic Issued by the Breast Team This leaflet gives you information about your discharge from the Breast Clinic. Why
More informationhelp yourself to Health screening exams to prevent cancer or find changes early
help yourself to Health screening exams to prevent cancer or find changes early pathways For Health include having screening exams when you are healthy to stay healthy. Talk with your health care provider
More information