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 Name
Last Name
Preferred Name
*
Name of Parents/Guardians if Under 18
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Marital Status
*
Married
Separated
Divorced
Widowed
Single
Live With
*
Spouse
Partner
Parents
Children
Friends
Alone
Number of Children
*
Occupation & Hours Worked Per Week
*
Current Diagnosis
*
Date Received
*
-
Month
-
Day
Year
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.
Submit
Should be Empty: