MCR Intake Form

Please answer each question as completely as possible.

Name

Date of Birth

YYYY

Phone Number

Email Address

Home Address

Do you have insurance? If yes, what type, and number?

Do you need financial assistance to help pay for your consultation or other cancer treatment?

Yes

Other

How were you referred to us?

Emergency Contact Name and Relationship

Emergency Contact Phone Number

What is your cancer diagnosis?

Who is your Oncologist and/or Primary Physician?

What cancer treatments have you received and when?

What other health conditions or challenges do you have or have you had?

Do you have any specific limitations, symptoms, or problems?

What health conditions do you have a family history of?

Do you have any allergies to medication or otherwise?

What prescription medications are you taking, amount, and frequency?

Do you take any vitamins or suppliments? If yes: type, amount, and frequency?

Do you drink alcohol? If yes: type, amount, and frequency?

Do you or have you ever smoked or been a smoker? If yes: type, amount, when, and for how long?

Do you take unprescribed or recreational drugs or medications? If yes: type, amount, and frequency?

Do you exercise? If yes: type, amount, and frequency?

What is your height?

What is your weight?

What are you looking to address in your consult?