First Name

Last Name

Email

Age:

Primary Diagnosis:–None–Anal CancerBreast CancerBladder CancerBone CancerColon / Rectal CancerEndometrial CancerKidney CancerLiver CancerLeukemia CancerLung CancerMelanoma / Skin CancerNon Hodgkins / Hodgkins LymphomaPancreatic CancerProstate CancerStomach CancerThyroid CancerOther (Please Specify)

Other Primary Diagnosis:

Date of Diagnosis:

Cancer Stage:–None–Stage 1Stage 2Stage 3Stage 4

Metastasis:Anal CancerBreast CancerBladder CancerBone CancerColon / Rectal CancerEndometrial CancerKidney CancerLiver CancerLeukemia CancerLung CancerMelanoma / Skin CancerNon Hodgkins / Hodgkins LymphomaPancreatic CancerProstate CancerStomach CancerThyroid CancerNoneOther (Please Specify)

Other Metastasis:

When did you find out the cancer spread:

What treatments have you done:ChemotherapyRadiationSurgeryImmunotherapyNoneOther (Please Specify)

Other Treatments Done:

What was the result of the treatments:GoodFairBadNoneOther (Please Specify)

Other Treatment Results:

Are you currently under medication:–None–YesNo

What medications are you on:High blood pressure medicationLow blood pressure medicationDiabetes medicationPain medicationChemotherapyAntibioticsNoneOther (Please Specify)

Other Medications:

What are your current symptoms:AnemiaBlood in urineBlood in stoolChange in bowel habitsDifficulty swallowingFatigueFrequent urinationHeadacheNauseaNonhealing soresPainPersistent coughSwollen glandsVaginal BleedingVomitingWeight lossNoneOther (Please Specify)

Other Symptoms:

History of cancer in the family:GrandfatherGrandmotherFatherMotherSiblingsNoneOther (Please Specify)

Other Relative:

Are there any other illnesses:DiabetesHigh blood pressureLow blood pressureHepatitisImmune suppressiveJaundiceNoneOther (Please Specify)

Other illnesses:

Do you currently have medical insurance:–None–YesNoNot Sure

Do you know what type of plan you have?:–None–HMOPPOEPOPOSHDHPHASNot sure

Name of your insurance company: