Questionnaire - UK Oncology

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First Name *

Last Name *

Date of Birth

Address *

Email *

Telephone No *

Gender

Male

Female

Height (cm)

Weight (kg)

BSA: (Office use)

Which hospital have you been attending for cancer treatment?

What is the name of the doctor in charge of your cancer care?

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Welcome to the UK-Oncology.com Medical Questionnaire

Thank you for completing this questionnaire, which is designed to find out a little about you and your recent and past medical history. In order to give you the most comprehensive opinion on your cancer and potential treatment we need to get as much information as possible. It helps us to understand how any treatment may affect you and your family. You do not need to answer each question perfectly but the more information the better for our consultant’s assessment of your case.

Your answers are confidential and will not be shared with anyone without your permission .You will be able to discuss your answers with any consultant assigned to your case. UK-Oncology.com will save your questionnaire securely and it will be encrypted if sent electronically.

In your own words please explain why, as you see it, you are seeking an opinion on your cancer

Briefly say what symptoms, if any, occurred which led to you seeing a doctor for cancer? If you have had an operation please describe what happened, what you understand of your operation and the results given to you by the surgical team

Please describe, as you understand it, what can be seen on any scans/x-rays that you have had

Please describe briefly what radiotherapy treatment, if any, you have had

Please describe briefly what chemotherapy treatment, if any, you have had and if you know any of the drugs, please list them

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PAST SURGICAL/MEDICAL HISTORY

Please list any other operations you have had in the past and at what age?

Past Medical Conditions - When or for how long?

Any other diseases/conditions - if so what and how long?

Any previous cancer diagnosis

if so what and when?

Current Medication-What medicines are you taking? (name and for how long)

Do you have any allergies?

Yes

No

If so, please tell us the medicine and what reaction it caused

Have you previously suffered from travel sickness and how bad?

Have you ever had Dental Implants fitted?

Yes

No

If so please tell us when these were done

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FEMALE REPRODUCTIVE HISTORY (PLEASE IGNORE IF MALE)

What AGE did you start your periods?

Are you still having periods?

Yes

No

If yes how often are your periods?

If past the menopause, at what approximate AGE did you last have a period?

Have you had the following removed

Womb (uterus)

Ovaries

At what age?

How many pregnancies have you had?

How many children have you had?

What was your age at your 1st pregnancy?

Are you now or have ever taken the contraceptive pill or HRT?

Yes

No

Brand names

Duration

Last time of use (date/year)

If you had children, did you suffer from morning sickness and how bad?

Is there anything else about your menstrual history that you would be willing to share with the consultant?

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FAMILY MEDICAL HISTORY

Are your parents alive?

Father

Yes

No

Mother

Yes

No

If your father died please tell us what caused his death and at what age.

Father

If your mother died please tell us what caused her death and at what age.

Mother

Is there any other history of cancer in your family?

No

Yes

If so, what type of cancer and at what AGE were they diagnosed?

Do you have brothers or sisters, who and age?

Have they or any other family member had cancer? - who and at what age?

Clotting (thrombo-embolic) events your family – who and age at diagnosis)

Does any other medical condition run in the family?

Is there anything else about your family history that you would be willing to share with the consultant?

If there is a particular specialist you would like to see please type there name here

Is there a specific region or hospital you would like to be seen in?

Please tick which methods of consultation you would be comfortable and which you prefer

THE END

Thank you for completing this questionnaire.

Do you have private medical insurance?

Yes

No

If “Yes” then please insert insurance details:

Insurance company:

Policy Number

By pressing SUBMIT, I consent that my questionnaire will be sent to UK Oncology’s Office via encrypted secure email. I confirm that I agree to the use of my/the patient’s personal data as per the GDPR statement on UK Oncology’s website homepage regarding the use and safeguarding of my/the patient’s personal information which will be sent to UK Oncology’s office and team. I also accept that, by submitting this questionnaire/email, from a data management perspective, the individual referred to in the questionnaire/email is entering into a “doctor-patient relationship” with UK-oncology.

Tick to Confirm *

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Welcome to the UK-Oncology.com Medical Questionnaire

PAST SURGICAL/MEDICAL HISTORY

SOCIAL INFORMATION AND LIFESTYLE

IF YOU HAVE CHILDREN, CAN YOU TELL US ABOUT THEM?

FEMALE REPRODUCTIVE HISTORY (PLEASE IGNORE IF MALE)

FAMILY MEDICAL HISTORY

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