Medical Information - Immunotherapy Institute

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First Name

Last Name

Age:

Primary Diagnosis:

Other Primary Diagnosis:

Date of Diagnosis:

Cancer Stage:

Metastasis:

Other Metastasis:

When did you find out the cancer spread:

What treatments have you done:

Other Treatments Done:

What was the result of the treatments:

Other Treatment Results:

Are you currently under medication:

What medications are you on:

Other Medications:

What are your current symptoms:

Other Symptoms:

History of cancer in the family:

Other Relative:

Are there any other illnesses:

Other illnesses:

Do you currently have medical insurance:

Do you know what type of plan you have?:

Name of your insurance company: