Patient History Form Date * Name * First Last Age * Sex * Male Female Are you pregnant? * Yes No Allergies Chronic illnesses Examples: Diabetes, high blood pressure, asthma, emphysema heart disease, etc. Previous Surgeries Do you have a living will? * Yes No Do you have Advanced Directives? * Yes No If yes to the above, we would appreciate a copy for our records. Previous Radiation Therapy Area Treated Radiation Oncologist Where Performed Date Previous Chemotherapy Medical Oncologist Date Family History of any of the following Cancer Diabetes Heart Disease High Blood Pressure Lung Disease Other If Other, please explain Social History Occupation Chemical or other environmental exposure Smoker Yes No Cigarettes per day Years Drinker Yes No Drinks per day Recreational drugs
