Comprehensive Oncology Medical History Form

Patient Information

• Full Name: _________________________ Date: //___
• Date of Birth: //___ Age: ____ Gender: ________
• Contact Number: _____________ Email: _________________

Current Cancer Status

• Primary Cancer Type: _________________________________
• Date of Initial Diagnosis: //___
• Current Stage: _____ Previous Stages: _____
• Treating Physician(s): _______________________________

Previous Cancer Treatments

Chemotherapy

• Previous Regimens: __________________________________
• Dates Received: ____________________________________
• Complications/Side Effects: ___________________________

Radiation Therapy

• Treatment Sites: ____________________________________
• Total Dose: __________ Number of Sessions: ___________
• Dates Received: ____________________________________

Surgical Procedures

• Type of Surgery: ___________________________________
• Date(s): __________________________________________
• Surgeon: _________________________________________

Family Cancer History

Current Symptoms

• Pain (Scale 1-10): ___ Location: ___________________
• Fatigue Level (Scale 1-10): ___
• Weight Changes: □ Loss □ Gain Amount: _____ lbs
• Other Symptoms: __________________________________

Current Medications

Medical History

Other Medical Conditions

□ Diabetes □ Heart Disease □ Hypertension □ Other: _____

Allergies

□ Medications □ Contrast Dye □ Other: ________________

Authorization

I confirm that the information provided above is accurate to the best of my knowledge.

Signature: ___________________ Date: //___