Neuro-Oncology

Blood-Brain Barrier Program

Patient Questionnaire

If you are interested in becoming a patient candidate, please call us at (503) 494-5626.

When you call us, it’s important that you share some information about yourself. Please feel free to download this questionnaire and take a few moments to answer the questions. If you prefer, you can fax (503-494-5627) this information before calling. Thank you.

General Information

Patient name:

Patient address:

Patient phone:

Name of contact person:

Relationship to patient:

Phone:

Address:

Medical Information

Age:

Gender:

Type of tumor:

Has patient had a biopsy or surgery? Yes No What was date?

Name of the hospital, city and state, where biopsy or surgery was done:

Has patient had chemotherapy?

Date of last treatment:

Has patient had radiation therapy?

Date of last treatment:

Name of physician currently treating patient:

Physician phone: