Providence Cancer Center - Clinical Trials Referral Form (Physician to complete)
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Providence Cancer Center - Clinical Trials Referral Form (Physicians to complete)
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 for assessment of possible clinical trials.
Our team may request more information in the form of medical records such as: Listing of oncology providers, history and physicals, pathology reports, imaging reports, and most recent lab results. You will be contacted within 48 hours of form submission during regular business hours.
Thank you for your interest in clinical trials.
Providence Cancer Center
Clinical Trials Department
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
Work Phone
Email
Performance Status
PS of 3 is NOT eligible
Allergies
(medication, food, environmental)
Peripheral Neuropathy
Yes
No
Grade
Tumor Type
Metastatic
Yes
No
If yes, where has it metastasized
to?
Second Primary
Yes
No
Where
Current Medications/Supplements with start date (please include all herbal and over the counter medications)
Cancer diagnosis details
Location of original diagnosis
Date of original diagnosis
History of cancer (areas cancer spread and date if applicable)
Other cancers in history (include date and treatment specifics)
Previous Cancer Treatment (including radiation, surgery, chemotherapy and immunotherapy)
Treatment Type
Start Date
Stop Date
Treatment
Treatment
Treatment
Treatment
Treatment
Treatment
Treatment
Treatment
Treatment
Treatment
Date of last treatment
(most studies require a patient to be off tx for at least 4 weeks prior to entering a Phase I study)
Brain Mets
Yes
No
Tx
Current use of Coumadin
Yes
No
Reason taking Coumadin/dosage
History of clotting
Yes
No
Comments
Current use of steroids
Yes
No
Reason taking steroids
Edema/Ascites/Effusions
Yes
No
Location
Biopsiable disease
Yes
No
Location
Diabetes
Yes
No
Comments
History of poor circulation
Yes
No
Comments
High blood pressure
Yes
No
Comments
Breathing problems
Yes
No
Comments
Supplemental oxygen use
Yes
No
Comments
Heart attack
Yes
No
Comments
Hepatitis
Yes
No
Specify
Anemia or low blood counts
Yes
No
Comments
Stroke
Yes
No
Comments
Thyroid problems
Yes
No
Comments
Rheumatoid disorder
Yes
No
Comments
HIV or Aids
Yes
No
Comments
Auto immune disorder
Yes
No
Specify
Kidney problems
Yes
No
Comments
Referring MD
Phone
Fax