EFTA00295983.pdf

CANCER CENTER FOR HEALING MEDICAL QUESTIONNAIRE Please fill out the medical questionnaire below. Once completed, please save and return as an attachment by email to . Once Dana receives the information she will contact you to arrange a consultation with one of our Cancer Team Doctors. After the consult we will customize a treatment plan. INSURANCE INFORMATION: Please provide Cancer Center For Healing with a front and back copy of your insurance card so we can verify coverage prior to your consultation. NOTE•: In lieu of medical records, please send all pertinent scan reports (MRI, Ultrasounds, PET) and all pertinent labs taken in the last 3 months to We do not accept records on CDs, please provide us with a word or PDF document. Patient Name: DOB: Age: Sex: Home Phone: Cell Phone: Who do we contact to set up the consultation (name & phone number): Email: Home Address: Street, City, State & Zip Date of Cancer Diagnosis: Type of Cancer (Pathology Diagnosis): 6 Hughes, Suite 120B I Irvine, CA 192618 www.cancercenterforhealing.com EFTA00295983  CANCER CENTER FOR HEALING Cancer Stage: Have you received Chemo? What dates did you receive treatment?: Have you received Radiation? What dates did you receive treatment?: Have you had surgery to treat your cancer? What date(s) did you have the surgery(s) on? Any Complications from previous treatments?: Date of last bloodwork: Date of last PET Scan: Therapies currently receiving for psychological/emotional wellbeing: Father's medical history: 6 Hughes, Suite 120B I Irvine, CAI 92618 www.cancercenterforhealing.com EFTA00295984  CANCER CENTER FOR HEALING Mothers medical history: Family medical history: Do you have a history of smoking or drinking? Have you ever been hospitalized? What was your diagnosis? What dates were you in the hospital? What is your dental history? Any major procedures Are you in pain?: Specify type of pain on a scale from 1 to 10: Pain medication type and dosage: When do you plan to start treatment with Cancer Center For Healing?: How did you hear about Cancer Center For Healing?: 6 Hughes, Suite 120B I Irvine, CA I 92618 www.cancercenterforhealing.com I EFTA00295985  CANCER CENTER FOR HEALING Additional information we should know: 6 Hu hes, Suite 120B I Irvine, CA I 92618 www.cancercenterforhealing.com I EFTA00295986