Symptoms Questionnaire for Young Adults

Are your symptoms a sign of something more serious? Please take a moment to complete this brief questionnaire. You may be contacted to schedule an appointment if one is appropriate for you. If you have any questions, please call Roswell Park toll-free at 1-800-ROSWELL (1-800-767-9355).

Fields marked with an asterisk * are required.

Personal Information

About You

First name *

Last name *

Date of birth * (mm/dd/yyyy)

Contact Methods

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

Your Patient's Email Address *

Best method to contact? Phone Email Text

Symptom Review

Tell us about your symptoms

What unusual symptom(s) are you concerned about? * Unusual lump or swelling in neck, breast, or testicle Blood in stool Spontaneous bruising Unexplained fever or illness that won't go away Frequent headaches with vision changes Loss of appetite or unexplained weight loss New mole or spot on skin that changes in size, shape or color Unintentional weight loss Other symptoms

Please list other symptoms *

How long have you been experiencing these symptoms? * Less than 1 week 1-2 weeks 3-4 weeks More than 4 weeks

Have you shared your symptoms with your primary care physician? * Yes No

Have you seen a specialist about your symptoms? * Yes No

Please explain what types of specialists you have seen *

Have you had any bloodwork or diagnostic testing done since you started experiencing your symptoms? * Yes No

Please explain what types of testing you have had done *

Insurance Information Optional

Primary insurance provider

ID number (Letters and Numbers only)