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 print 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: |
