Providence Cancer Center - Clinical Trials Patient Interest Form
Time Elapsed:
0
minutes
Time Remaining:
0
minutes
Total Time:
0
minutes
Anonymous Login Code:
Code Entry Page
Save this code which is required to update your response at a later time.
Providence Cancer Center - Clinical Trials Patient Interest Form
Please complete the items below to the best of your ability. Once completed, click “done” to send the form to the Providence Cancer Center Clinical Trials Department. The form will automatically be sent to to the department for assessment of possible clinical trials. Depending on the amount of information provided, Providence Cancer Center Clinical Trials Staff may request more information in the form of medical records.
Please be prepared to send the following documents: Oncology doctor’s history and physical, pathology reports, imaging reports, and most recent blood work lab results.
You will be contacted within 48 hours of form submission(during regular business hours).
Name of person completing this form
*
Contact phone
*
Patient Name
*
Today's Date
Date of Birth
Age
Sex
Female
Male
Address
City
State
Zip
Phone
Cell
Email
Occupation
Work Phone
How did you hear about us?
Current Physicians and Location
Name/location:
Specialty:
Phone:
Physicians and Location:
Physicians and Location:
Physicians and Location:
Significant Health History
Allergies
(medication, food, environmental)
Current Medications/Supplements with start date (please include all herbal and over the counter medications)
Cancer diagnosis details
Location of original diagnosis (what part of the body) and date of diagnosis
History of cancer (areas cancer spread and date if applicable)
Do you have a history of other cancers? If so, please list dates and treatment specifics.
Previous Cancer Treatment (including radiation, surgery, chemotherapy and immunotherapy)
Treatment Type
Start Date
Stop Date
Treatment
Treatment
Treatment
Treatment
Treatment
Have you Ever Been Treated for any of the Following? If yes, please list specifics in next question under other medical concerns.
No
Yes
History of poor circulation
High blood pressure
Heart attack
HIV or Aids
Diabetes
Breathing problems like asthma or emphysema
Hepatitis (if yes, specify below)
Anemia or low blood counts
Stroke
Thyroid problems
Rheumatoid disorder
Supplemental oxygen use
Auto immune disorder (if yes, specify below)
Current use of immuno-suppressive agents
Kidney problems
Taking blood thinners
Have you had brain metastasis?
Please List Any Other Medical Concerns
Please List All Prior Hospitalizations related to your cancer (include date and reason)
While you are waiting to hear from the Clinical Trials Department, please fax the following to
503-215-6725
, Attn: Clinical Trials Screening
1. Any recent lab work (blood work)
2. Most recent doctor visit chart note
3. Pathology reports
Additional Comments