New Cancer Patient Screening Form

New Cancer Patient Screening Form

Please complete all questions to the best of your ability prior to your Screening Appointment with Root Causes Medicine.
Name

First NameLast Name
Preferred Name
Name of Parents/Guardians if Under 18
Date of Birth

MonthDayYear
Date
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Marital Status
Live With
Number of Children
Occupation & Hours Worked Per Week
Current Diagnosis
Date Received

MonthDayYear
Date
Current Medications & Supplements
Please list any prescription, over-the-counter medications, or vitamins/supplements you are taking and dosages.
Surgical History
Please list any surgeries that have occurred in your care timeline and the date they were performed.
Integrative Care
Please list any integrative care treatments (IV C, mistletoe, ozone, etc.) that have occurred in your care timeline and the date they were performed/received.
Chronological Timeline
To provide a comprehensive view of your health journey, please list in order by date any major events, procedures, or treatments that have occurred since your initial diagnosis.
Miscellaneous
Please share any other pertinent information you'd like Dr. Lucas to be aware of.
Should be Empty: