Patient Request Form:
Patient Name:
Patient Advocate Name
(If different than patient)
:
Type of Cancer
(exact, full diagnosis)
:
Stage of Cancer:
What are your current symptoms?:
Pain (specify where and how much in the Notes below)
Fatigue/engergy much lower than normal for me
Impared ability to remember and think clearly
Depression
Mood Swings
Incontinence
Fever
Vomiting
Vision Unclear
Symptom Notes:
Specify how and how much this has changed your life. Try to anticipate other patients questions about where, when, how and how much?
Treatment received in the past 7 days:
Standard Treatments
Surgery
Radiation
Chemotherapy
Treatment holiday, as recommended by physician
Patient decision to do nothing for now
Please add notes that may help other patients make better decisions for themselves.
New Treatments
Gleevec
Iressa
Tarceva
Herceptin
Please add notes that may help other patients make better decisions for themselves.
Completmentary Treatments
Spiritual practice
Acupuncture
Massage
Yoga or Tai Chi
Chiropractic
Nutritional Supplements
Chinese Herbs
Special Diet
Treatment Notes
Please add notes that may help other patients make better decisions for themselves.
Name of person we can contact if needed?:
Phone # of contact person and convenient times to call:
Email address of contact person:
Name of Physician(s) monitoring patient's treatment, and their speciality?:
Physician #1
Specialty
May we contact this doctor if needed:
Yes
No
Physician's Phone #:
Physician's Email Address:
Physician #2
Specialty
May we contact this doctor if needed:
Yes
No
Physician's Phone #:
Physician's Email Address:
Physician #3
Specialty
May we contact this doctor if needed:
Yes
No
Physician's Phone #:
Physician's Email Address: