dedicated to curing cancer today. cancercarewny.com
|
|
|
- Deborah Lynch
- 6 years ago
- Views:
Transcription
1 dedicated to curing cancer today. cancercarewny.com
2 our team Radiation Oncology Michael Duff, M.D. is a board-certified radiation oncologist and graduate of the SUNY at Buffalo School of Medicine. He completed an internship in Internal Medicine in Buffalo, and trained in radiation oncology at the University of Minnesota. Dr. Duff is an active member of the American Society for Therapeutic Radiology and Oncology (ASTRO). He is well versed in various radiation techniques, such as 3D conformal radiation therapy and Intensity Modulated Radiation Therapy (IMRT). Dhiren K. Shah, M.D. is a board-certified radiation oncologist. He graduated with honors from Lehigh University and completed his radiation oncology training at Robert Wood Johnson/Cooper Hospital in New Jersey. He is a member of many clinical societies, including the American Society for Therapeutic Radiology and Oncology, is a fellow of the American College of Radiation Oncology and is the vice chair for the prestigious New York State Board of Medicine. Christina Mangovski, RPA-C graduated with a master s degree in the Physician Assistants Program at LeMoyne College in Syracuse, NY. She is nationally certified by the National Commission on Certification of Physician Assistants and is an active member of the American Academy of Physician Assistants. Urologic Pathology William A. Geary, M.D., PhD graduated from the University of Virginia School of Medicine, where he also completed his pathology training. Dr. Geary is a board-certified physician and an active member of various professional organizations. John E. Schrecengost, M.D. is a board-certified physician who graduated from the University of Pittsburgh School of Medicine, and completed his pathology training at the University of Virginia Health Sciences Center. Dr. Schrecengost is also an active member of multiple professional organizations.
3 our philosophy Cancer Care of Western New York is dedicated to providing the best cancer care for our patients. Our facilities have the latest technology for the treatment of cancer throughout the region. Many different types of cancers can be treated successfully with radiation, including the following: Prostate Cancer The cause of prostate cancer remains unknown. The risk of developing prostate cancer increases as a man ages. A family history of prostate cancer in a brother or a father also doubles one s chances of getting prostate cancer. In the very early stages of prostate cancer, there usually are no symptoms. Breast Cancer Breast cancer is the most common cancer in women. Some symptoms associated with breast cancer are a new lump in the breast or underarm, thickening or swelling of the breast, irritation/dimpling of the breast, pain in the nipple area, and nipple discharge. Lung Cancer Lung cancer is a disease caused by the rapid growth and division of cells that make up the lungs. Coughing, shortness of breath, wheezing, chest pain, loss of appetite and weight loss are common symptoms experienced with lung cancer. Central Nervous System (CNS) Cancer CNS cancer affects either the brain, spinal cord or both. Signs and symptoms include headache, seizures, and neurological dysfunction affecting speech, memory, and/or vision. Gamma Knife is a radiosurgery technique that has proven very effective in the treatment of CNS cancers.
4 Head and Neck Cancer This type of cancer is one that occurs in the head, nasal cavity, sinuses, lips, mouth, salivary glands, throat or larynx. Common symptoms of cancer of the head and neck include persistent pain in the throat, pain/difficulty swallowing, persistent hoarseness or change in voice, pain in the ear and bleeding in the mouth or throat. Bladder Cancer Carcinogens (cancer causing agents) in the urine may lead to the development of bladder cancer. The primary symptom is blood in the urine. Other symptoms may include frequent urination and pain upon urination. Gastrointestinal (GI) Cancer GI cancer can form in the lining of the GI tract, which includes the small intestine, large intestine, stomach, pancreas and liver. Depending on the location of the cancer, causes, risk factors, and symptoms may vary. Other cancers successfully treated by radiation include: Testicular Cancer Colorectal Cancer Leukemia Thyroid Cancer Sarcomas Lymphomas (including Hodgkin s & non-hodgkin s) Skin Cancer Cervical Cancer Ovarian Cancer Metastatic Cancers And Many Others Our goal is to cure cancer.
5 patient information Affiliations Kaleida Health Millard Fillmore Gates Circle Hospital Millard Fillmore Suburban Hospital DeGraff Memorial Hospital Catholic Health System Kenmore Mercy Hospital Mercy Hospital of Buffalo Sisters of Charity Hospital St. Joseph Hospital Buffalo Ambulatory Surgery Center Erie County Medical Center Gamma Knife Radiosurgery Insurance Blue Cross & Blue Shield of Western New York Blue Shield General Motors Community Blue Empire Plan Encompass 65 Excellus Fidelis GHI Health America/Health Assurance Highmark Blue Cross Blue Shield Independent Health (IHA) Medicaid Medicare North AmeriCare NOVA Private Insurances Senior Blue Senior Choice United Healthcare Univera UPMC Workers Comp/No Fault If you don t see your plan listed, please call our office. Dr. Dhiren K. Shah performs this specialized service at Roswell Park. cancercarewny.com Harlem Professional Park 3085 Harlem Road, Suite 200, Cheektowaga, NY PH: FX: Jamestown 117 Foote Avenue, Jamestown, NY PH: FX:
dedicated to curing cancer today. cancercarewny.com
dedicated to curing cancer today. cancercarewny.com our philosophy Cancer Care of Western New York is dedicated to providing the best cancer care for our patients. Our facilities have the latest technology
New 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
PATIENT INFORMATION FORM (WOMEN ONLY)
PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for
Name. 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
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
Radiation Oncology Study Guide
Radiation Oncology Study Guide For the Initial CertificationQualifying (Computer-Based) Examination General and Radiation Oncology This examination is designed to assess your understanding of the entire
TOMBALL 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
Dear Mercy Cancer Center Radiation Oncology Patient
Dear Mercy Cancer Center Radiation Oncology Patient Welcome to our Department. In order to complete our records, and enable our physicians to ensure that your questions are fully addressed, we appreciate
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
Greater Baltimore Medical Center Sandra & Malcolm Berman Cancer Institute
2008 ANNUAL REPORT Greater Baltimore Medical Center Sandra & Malcolm Berman Cancer Institute Cancer Registry Report The Cancer Data Management System/ Cancer Registry collects data on all types of cancer
Pharmacy Name/Location/Phone number:
Pharmacy Name/Location/Phone number: Family Physician Name: Phone: Address: Referring Physician Name: Phone: Address: First Emergency Contact: Relationship: Home/cell phone: Work phone: Second Emergency
Arcana Center for Integrative Medicine
Arcana Center for Integrative Medicine Patient s Name: Date of Birth: Reason for today s visit: Past Medical History Primary care physician: Date of last exam: (sick or well) Physician s Address: Office
NEWS A Publication of Vantage Oncology, Tri-State Radiation Oncology Centers - TROC
Congressman Larry Buschon Visits Evansville Cancer Center Nationwide, physicians who provide care to Medicare patients are feeling the impact of significant reimbursement cuts for their services. Members
Re-Screening Medical History Questionnaire
Building Trades National Medical Screening Program Re-Screening Medical History Questionnaire Name: Address: _ City: _State: Zip Phone Number (include Area Code): Social Security # Date of Birth If female,
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
CANCER FREE, SIX YEARS AND COUNTING!
YOUR ANSWER TO CANCER. CANCER FREE, SIX YEARS AND COUNTING! Kim evens BREAST CANCER SURVIVOR nrocdoctors.com We re Here To Help. At NROC, patients always come first. As your partners in cancer care, we
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
Oncology 101. Cancer Basics
Oncology 101 Cancer Basics What Will You Learn? What is Cancer and How Does It Develop? Cancer Diagnosis and Staging Cancer Treatment What is Cancer? Cancer is a group of more than 100 different diseases
FACULTY MEMBERSHIP APPLICATION Tulane Cancer Center
FACULTY MEMBERSHIP APPLICATION Tulane Cancer Center 1430 Tulane Ave., Box SL-68, New Orleans, LA 70112-2699 J. Bennett Johnston Building, Mezzanine (Floor 1A), Suite A102 (504) 988-6060, fax (504) 988-6077,
John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter
John Wayne Cancer Institute Dr. Foshag Essner Dr. Fischer Dr. Faries Dr. Foshag Dr. Bilchik Dr. O'Day Dr. Leuchter Medical Questionnaire Reset Form Date: Name: Gender: Male Female Age: Last First Middle
NEUROLOGICAL SURGERY, P.C.
NEUROLOGICAL SURGERY, P.C. PATIENT INFORMATION Name Date of Birth Age Address City Sate NY Zip Home ( ) - Cell ( ) - Work ( ) - Ext: Email Address _ Sex M F Soc. Sec. #: / / Single Married Widowed Separated
A BETTER TOMORROW STARTS WITH THE BEST OF TODAY PATIENT BROCHURE
A BETTER TOMORROW STARTS WITH THE BEST OF TODAY PATIENT BROCHURE 1 WELCOME TO THE CALIFORNIA PROTONS CANCER TREATMENT CENTER Patient Care is at the Center of Everything We Do Located in San Diego, California
Welcome to About Women by Women
Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner
MEDICAL HISTORY RECORD
MEDICAL HISTORY RECORD Please print and complete all information. Case. Male Female Medicare. Medicaid. Today s Date Birthdate Last Name First Middle Daytime Phone Home Phone Address City Marital Status
A. 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
2011 CAYUGA MEDICAL CENTER CANCER COMMITTEE
11 CAYUGA MEDICAL CENTER CANCER COMMITTEE Charles Garbo, MD, Chairman Board certified in medical oncology and internal medicine. Graduated University of Vermont Medical School, Burlington, VT. Internship
Annual Report. Cape Cod Hospital and Falmouth Hospital Regional Cancer Network Expert physicians. Quality hospitals. Superior care.
Annual Report Cape Cod Hospital and Falmouth Hospital Regional Cancer Network 2013 Expert physicians. Quality hospitals. Superior care. Cape Cod Hospital s Davenport- Mugar Hematology/Oncology Center and
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
Cancer Institute. cancer institute Program overview Report 2013
Cancer Institute cancer institute Program overview Report 2013 Saint Francis Medical Center in Cape Girardeau, Mo., is a regional leader in the battle against cancer, bringing new techniques, ideas and
Margie 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
2. Occupancy rate of beds in the hospital: Occupancy rate of at least 60%
Appendix A Training Centre Accreditation Checklist A. Accreditation of the HOSPITAL 1. Total number of beds in the hospital : Minimum 500 beds 2. Occupancy rate of beds in the hospital: Occupancy rate
Intensity Modulated Radiation Therapy (IMRT)
Intensity Modulated Radiation Therapy (IMRT) Policy Number: Original Effective Date: MM.05.006 03/09/2004 Line(s) of Business: Current Effective Date: HMO; PPO 06/24/2011 Section: Radiology Place(s) of
Silver Child Development Center New Patient Questionnaire. Relation (circle) Biological Mother Stepmother Adoptive Mother
Silver Child Development Center New Patient Questionnaire Today s Date Mother s Name First Last Date of Birth Relation (circle) Biological Mother Stepmother Adoptive Mother Foster Mother Other Father s
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
![Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?](/thumbs/87/97078208.jpg "Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?")
ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
Initial Patient Intake Form
Initial Patient Intake Form Patient Registration Today s Date Patient Name (last) (first) (middle) Address (city) (state) (zip) Date of birth (mm/dd/yyyy) SSN # Current Gender Identity: Male Female Transgender
Oncologic Care for Old-Aged Patients
Oncologic Care for Old-Aged Patients Elderly & Cancer People 65 years or older are at the higher risk for cancer. For all cancers combined, those over 65 years have an incidence rate 10 times greater than
PATIENT MEDICAL HISTORY PATIENT INFORMATION
PATIENT MEDICAL HISTORY PATIENT INFORMATION Name: Referred here by: Self Family Friend Doctor Other Health Professional If Doctor, please give name & address: List doctors seen in the last 24 months: Relative(s)
Truman Medical Center-Hospital Hill Cancer Registry 2014 Statistical Summary Incidence
Truman Medical Center-Hospital Hill Cancer Registry 2014 Statistical Summary Incidence In 2014, there were 452 new cancer cases diagnosed and or treated at Truman Medical Center- Hospital Hill and an additional
Premier 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
MEDICAL 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
Patient Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
MEDICAL 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
CAPITAL HEALTH CENTER FOR ONCOLOGY. capitalhealth.org/oncology
CAPITAL HEALTH CENTER FOR ONCOLOGY capitalhealth.org/oncology Cancer can be a life altering illness. That s why the Capital Health Center for Oncology offers compassionate, personalized care led by a closely
NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.)
NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.) TODAY'S DATE Your age DATE OF BIRTH YOUR NAME (Last) (First) (M.I.) REFERRED HERE BY YOUR PAST MEDICAL HISTORY (If YOU have
Patient Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
2011 to 2015 New Cancer Incidence Truman Medical Center - Hospital Hill
Number of New Cancers Truman Medical Center Hospital Hill Cancer Registry 2015 Statistical Summary Incidence In 2015, Truman Medical Center diagnosed and/or treated 406 new cancer cases. Four patients
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
Revolutionizing Treatment * Restoring Hope * Improving Lives
Revolutionizing Treatment * Restoring Hope * Improving Lives 6802 S. Olympia Ave., Suite G100 Tulsa, Oklahoma 74132 Phone: 918-949-6676 Fax: 918-949-6670 Please fill out the all paperwork and bring it
Cancer 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
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
This 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
2016 Cancer Registry Annual Report
2016 Cancer Registry Annual Report Cancer Committee Chairman s Report The Cancer Committee at Cancer Treatment Centers of America (CTCA) at Eastern Regional Medical Center (Eastern), established in 2006,
Providence 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
Discussing TECENTRIQ (atezolizumab) with your healthcare team
Discussing TECENTRIQ (atezolizumab) with your healthcare team What is TECENTRIQ? TECENTRIQ is a prescription medicine used to treat: a type of lung cancer called non-small cell lung cancer (NSCLC). TECENTRIQ
Capital 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
Health 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
Reason forappointment:
Patient Information Date / / Patient Name (last, first) Sex: Male / Female Home Phone # ( ) Cell Phone # ( ) E-Mail Address Address City State Zip Code Date of Birth / / Age Occupation Who Referred You
Corporate Medical Policy
Corporate Medical Policy Intensity Modulated Radiation Therapy (IMRT) of Head and Neck File Name: Origination: Last CAP Review: Next CAP Review: Last Review: intensity_modulated_radiation_therapy_imrt_of_head_and_neck
Cancer Care Kenya Notes for General Practioners:
Cancer Care Kenya Notes for General Practioners: Site specific symptoms for detecting cancers at an early stage is given below. Please refer patients for detailed work up. 1. Brain /CNS tumors: Sub acute
PULMONARY MEDICINE PATIENT QUESTIONNAIRE
PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical
FIRST TIME VISIT APPOINTMENT CHECKLIST Department of Radiation Oncology 200 Medical Plaza, Ste B265 Los Angeles, CA
Department of Radiation Oncology FIRST TIME VISIT APPOINTMENT CHECKLIST Department of Radiation Oncology 200 Medical Plaza, Ste B265 Los Angeles, CA 90095 310-825-9775 1. Complete ALL important Patient
PATIENT 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:
KEY TO LIFE CHIROPRACTIC
KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office?
Form.NewPatientHstory_PrecisionEndoRev Page 1 of 5
Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact#: Alternate#: Work#: Date of Birth: / / Sex: Male Female SS# (optional): Marital Status : Single Married Divorced
Northern Monmouth County Medical Associates
Northern Monmouth County Medical Associates 195 Route 9; Suite 112 Manalapan, NJ 07726 (732)345-2070 FAX: (732) 345-2072 DATE: COMPLETE MEDICAL HISTORY FORM NAME: AGE: DATE OF BIRTH: I. CHIEF COMPLAINT:
Patient 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:
Name: 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
Head and Neck Cancer. What is head and neck cancer?
Scan for mobile link. Head and Neck Cancer Head and neck cancer is a group of cancers that usually originate in the squamous cells that line the mouth, nose and throat. Typical symptoms include a persistent
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
PATIENT 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
PATIENT 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
Medication Allergies
**PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.
2009 Cancer Program Annual Report
2009 Cancer Program Annual Report with statistical data from 2008 Focus : Breast Cancer Lake Cumberland Regional Hospital 305 Langdon Street Somerset, KY 42503 Telephone: 606-679-7441 Fax: 606-678-9919
Mercy MS Center New Patient Information
Mercy MS Center New Patient Information Last Name: First Name: DOB: MULTIPLE SCLEROSIS HISTORY Reason for clinic visit: I have been diagnosed with MS or NMO (Date diagnosed ) I have not been diagnosed
Medical Questionnaire
MEDICIS Health Testing Center Avenue de Tervueren 236 115 Bruxelles Tel : 2/762.5.44 Medical Questionnaire Name :. Maiden name : First name :. Sex :. Address :...... Phone (private) : Office :. Date of
SCOTTISH CANCER REFERRAL GUIDELINES REVIEW 2018
SCOTTISH CANCER REFERRAL GUIDELINES REVIEW 2018 Dr Peter Hutchison, Chair of Review Group WHAT & WHY? Scottish Cancer Referral Guidelines 2014 Scottish Primary Care Cancer Group identified need for some
Philippine 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,
Primary Chief Complaint 1. Location 2. When did this begin? 3. How did this begin?
Name Date These questions that you are about to answer are very important for the Doctor. They will enable the doctor make a complete and diagnosis, and provide medical documentation (if needed)to your
Who is filling out this intake form? Self Spouse Parent Guardian
Office Use Only: Reviewed with Patient Data Entry Scan & File Date: Date: Date: Initials: Initials: Initials: Today s Date: Who is filling out this intake form? Self Spouse Parent Guardian If you are not
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment
PATIENT HEALTH INFORMATION SHEET
. Norman J. Brodsky, M.D. Board Certified Michael D. Gauwitz, M.D. Diplomate, ABR Taghrid A. Altoos, M.D. Radiation Oncology Hiral K. Shah, M.D. PATIENT HEALTH INFORMATION SHEET NAME: DATE OF BIRTH: AGE:
NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-
PRIMARY CARE (719)
PRIMARY CARE (719) 522-1133 Please help us in meeting your health care needs by providing the following information. *Children under 13, please use Pediatric Health History only. Thank you! Patient: Who
Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status
PATIENT HISTORY RECORD FACULTY INTERNAL MEDICINE. Date of Appt: / / Name: Date of Birth: / / Last First Middle
PATIENT HISTORY RECORD FACULTY INTERNAL MEDICINE Date of Appt: / / Name: Date of Birth: / / Last First Middle The information you provide today is very important in regards to your healthcare. Please answer
Cancer Care at HackensackUMC Mountainside. Unsurpassed Quality, Safety, Comfort and Convenience
Cancer Care at HackensackUMC Mountainside Unsurpassed Quality, Safety, Comfort and Convenience A Nationally Recognized Standard of Care A Supportive, Community Setting In the years that HackensackUMC Mountainside
Please 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
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM PATIENT INFORMATION Last
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
HD CLINIC MEDICAL HISTORY FORM
HD CLINIC MEDICAL HISTORY FORM Welcome to the HDSA Center of Excellence HD Clinic. Please take a few moments to answer the questions below as best as you can. If you need assistance, a caregiver/companion
Name: 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
What is head and neck cancer? How is head and neck cancer diagnosed and evaluated? How is head and neck cancer treated?
Scan for mobile link. Head and Neck Cancer Head and neck cancer is a group of cancers that start in the oral cavity, larynx, pharynx, salivary glands, nasal cavity or paranasal sinuses. They usually begin
Health History Questionnaire:
Health History Questionnaire: Name Date of birth Address Local phone number Please describe what problem or concern brought you to our office today: Alternative phone number Primarily to establish care
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
Marsha Haley, M.D. Training. Resident Physician, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania, 2005 to 2009.
Marsha Haley, M.D. Training Resident Physician, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania, 2005 to 2009. Surgical Intern, University of Virginia Health Sciences Center, Charlottesville,
Patient Information Form
Patient Information Form Welcome to the Department of Radiation Oncology We want to provide excellent service. The following information will allow us to accurately handle your billing and insurance. First