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Where did you find us?
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Who referred you?
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Name of caller
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Relationship to patient
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Legal Name of Patient
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Name preferred for patient
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Patient Date of Birth
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Pediatric Patient
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Primary Phone
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Additional Phone Contact
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Primary Email
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Additional Email
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Names of additional family members/support that you would like us to have
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Are you under the care of an Oncology physician?
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When was your last appointment with an oncologist
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Other practitioners
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Street
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City
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State
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Zip
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Time Zone
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Country
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Canadian Province
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ADDITIONAL INFORMATION FORM
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Primary cancer diagnosis
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When diagnosed?
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Stage
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Metastasis
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Diagnosis details (e.g. HER2 +, lung, liver mets)
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Date of Recurrence if applicable
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When was your most recent scan?
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Scan Results
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When was your most recent blood work?
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Lab Results
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Current cancer treatments
• • •
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Others, please specify
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Past treatments
• • •
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Others, please specify
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What other diagnoses do you have?
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How would you rate your overall health?
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How would you rate physical activity level?
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Do you experience appetite disturbances?
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Have you experienced recent weight loss?
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Do you experience difficulty with swallowing?
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If yes
• • •
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Anything special we need to know
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How are you feeling today?
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Initial Consultation Offered
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COC Physician Preference
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If declined appt-Why?
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