Cancer Survivorship

Your Information

About You

First name *

Last name *

Are you calling for yourself, or on behalf of someone else? * For myself For someone else

Date of birth * (mm/dd/yyyy)

About The Patient

Patient's first name *

Patient's last name *

Patient's date of birth *

Your relationship to the patient *

Your Phone Number * (###-###-####)

Have you Has the patient ever been seen at Roswell Park? * Yes No

Patient MRN *

How did you hear about Roswell Park?

Please explain *

Your Patient's Contact Information

Contact Methods

Your Patient's Phone number * (###-###-####)

Alternate phone (###-###-####)

Your Patient's Email Address *

What is the best method to contact you the patient? * Phone call Email

Best time to call *

Would you the patient like to join our mailing list? Yes No

Demographics

About YouThe Patient

Your Patient's Metrics

YourThe patient's height

feet inches

YourThe patient's weight

pounds

Your Patient's Education

What is the highest level of education you havethe patient has completed? * Less than high school High school or GED Vocational or technical school Associate's degree or some college Bachelor's degree Graduate or professional degree

Appointment Type & Location

Preferred Location

Appointments are being offered at Roswell Park and our Care Network Partners *

Please select the location you prefer

Roswell Park Comprehensive Cancer Center Main Hospital
Elm & Carlton Streets, Downtown Buffalo RPCI Amherst Center
100 College Parkway, Suite 290, Williamsville Roswell Park Care Network Member
21 Porter Avenue, Jamestown Roswell Park Care Network Member
6000 Brockton Drive, Lockport Roswell Park Hematology Oncology Northtowns
199 Park Club Lane, Suite 200, Williamsville

In the event of cancellation, are youis the patient interested in same or next day appointments? * Yes No

Medical History

Your Patient's Past Diagnoses

Have you ever been diagnosed with cancer? * Yes No

What types of treatment have you has the patient received as part of your their care? * Chemotherapy Radiation therapy Integrative therapy Immunotherapy Radiation Surgery Transplant Other

What other treatment was involved? *

Your Patient's Medical Screening

Have you ever been vaccinated for HPV? I don't know Yes No

Smoking & Tobacco Use

Smoking & Tobacco Use History

Have you ever smoked cigarettes? * Yes No

Have you smoked at least 100 cigarettes in your life? * 100 cigarettes is approximately 5 packs. Yes No Not sure

Do you currently smoke cigarettes? * Every day Some days Not at all

How old were you when you first started to smoke cigarettes? *

About how many cigarettes do you usually smoke per day? * One pack contains 20 cigarettes

Over the past 30 days, how many days did you smoke cigarettes? *

How old were you when you first started to smoke cigarettes? *

When you last smoked cigarettes, about how many cigarettes did you usually smoke per day? * One pack contains 20 cigarettes

How old were you when you last smoked cigarettes? *

Have you ever used electronic cigarettes? * Also known as e-cigs or vape pens Yes No

How frequently do you use electronic cigarettes? * Every day Some days Rarely Not at all

For how long have you used, or did you use, electronic cigarettes? * Less than 1 year 1-2 years 3-4 years 5 or more years

Have you used chewing tobacco at least 20 times in your life? * Brands such as Redman, Levi Garrett, Beech-Nut, etc. Yes No

Have you ever smoked any of the following substances? * Please choose all that apply. Cigar Hookah Marijuana Other None

How frequently do you smoke cigars? * Every day Some days Rarely

When you smoke cigars, do you inhale? * Yes No

Total Pack Years:

Insurance & Physician Information

About Your Insurance

Primary insurance provider *

ID number * (Letters and Numbers only)

About Your Primary Care Physician Optional

Primary physician

Primary physician's phone (###-###-####)

Your Patient's Residential Address