UPMC CANCERCENTER
INTEGRATIVE ONCOLOGY PROGRAM
INTAKE FORM
Personal Information
Last name: __________________________________ First name: _________________________________________ Gender: ______
DOB: (DD/MM/YYYY) ______ /______ /________
Age: ______
PCP: ___________________________________________ Medical Oncologist: ____________________________________________
Radiation Oncologist: _____________________________ Other (specialist): ______________________________________________
What are your goals for today’s visit? ________________________________________________________________________________
__________________________________________________________________________________________________________________
I was referred by
MD ______________________________________ Myself Other ________________________________
Cancer Specific Information Treatments
Cancer Type: ________________ Stage: ______ Recurrence: Y N
Date: (DD/MM/YYYY) Complications
Drugs Used (if applicable) and Comments:
Biopsy
_____/_____/_____
Y N
______________________________________
Surgery
_____/_____/_____
Y N
______________________________________
Chemotherapy
_____/_____/_____
Y N
______________________________________
Radiation
_____/_____/_____
Y N ______________________________________
_____/_____/_____
Y N ______________________________________
_____/_____/_____
Y N ______________________________________
Hormone Therapy
Other: __________________ Page 1
UPMC CANCERCENTER
INTEGRATIVE ONCOLOGY PROGRAM
Medical Information
Allergies, if known (medical, environmental, foods): ___________________________________________________________
Please list all medications and supplements/natural health products taken regularly:
Name of drug or supplement:
Taken for:
Dose (amount and frequency):
Do you smoke now? Yes No Have you ever smoked? Yes No Are you frequently around people that do smoke? Yes No Did it help and how?
Social History
Smoking:
Diet:
Do you eat three to five meals a day?
Yes No Do you eat snacks throughout the day? Yes No Are you on a special diet? Yes No If yes, please describe:
___________________________________________________________________________________
___________________________________________________________________________________
Occupation:
Are you currently working?
Yes No If yes, how many hours?
Yes No Yes No Yes No _______ Religious/Spiritual:
Do you practice a religion? Do you believe in a higher power?
Support System:
Do you have a support system? If yes, please describe:
__________________________________________________________________________________
__________________________________________________________________________________
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UPMC CANCERCENTER
INTEGRATIVE ONCOLOGY PROGRAM
Current State
Please circle the number that best describes how you feel now:
NAUSEA None 0
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10
Worst Possible
PAIN None 0
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Worst Possible
TIREDNESS: decreased energy level (but not necessarily sleepy) None 0
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Worst Possible
DROWSINESS: sleepiness None 0
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Worst Possible
WELL-BEING: overall comfort
None 0
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Worst Possible
ANXIETY: nervousness or restlessness None 0
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Worst Possible
DEPRESSION: sad or blue None 0
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Worst Possible
SHORTNESS of BREATH None 0
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Worst Possible
APPETITE None 0
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Worst Possible
2
Is there anything else that you feel may be important for us to know?
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
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UPMC CANCERCENTER
INTEGRATIVE ONCOLOGY PROGRAM
Please indicate how much you agree with the following statements as they apply to you over the last month.
If a particular situation has not occurred recently, answer according to how you think you would have felt.
Not true at all = 0
Rarely true = 1
Sometimes true = 2
2. I can deal with whatever comes my way. Often true = 3
0
2 3
4
4. Having to cope with stress can make me stronger. 1. I am able to adapt when changes occur.
1
True nearly all the time = 4
3. I try to see the humorous side of things when I am
faced with problems.
5. I tend to bounce back after illness, injury, or other
hardships.
6. I believe I can achieve my goals, even if there are obstacles.
7. Under pressure, I stay focused and think clearly.
8. I am not easily discouraged by failure.
9. I think of myself as strong person when dealing with
life’s challenges and difficulties. 10. I am able to handle unpleasant or painful feelings
like sadness, fear, and anger.
Patient Signature _________________________________________________________ Date_________________________
Physician Signature _______________________________________________________ Date_________________________
Page 4