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Patient History
Northern Illinois Cancer Treatment Center
 
Everyone I was involved with at the facility was friendly, caring, and compassionate which made this hard experience much easier. - Connie
 

Patient History Questionaire

Fill out the form below to submit your paitent history information.

 
Patient Information
Emergency Contact & First Visit Info.
Medical History - Cancer (Have You Ever Had Any of the Following?)
Medical History - Neurology (Have You Ever Had Any of the Following?)
Medical History - Lung (Have You Ever Had Any of the Following?)
Medical History - Gastrointestinal (Have You Ever Had Any of the Following?)
Medical History - Heart (Have You Ever Had Any of the Following?)
Medical History - Renal (Have You Ever Had Any of the Following?)
Medical History - Other (Have You Ever Had Any of the Following?)
GYN
Do You Have Any of The Following?
Surgeries (List the operation and the year it was performed.)
Add Another Surgery
Traumas (List the trauma and/or fracture and the year it occured.)
Add Another Trauma
Allergies (List the allergy and your body's reaction.)
Add Another Allergy
Medications (List all Medications you are currently taking.)
Add Another Medication
Social History
Family History
Family History of Cancer (Family members had cancer?)
Alternative Health Treatments (Do you use any of the following?)
Insurance Information
Form Signature
I verify the above information is true and correct to the best of my belief.