Oncology Questionnaire – BIH WEBSITE

Oncology Questionnaire

Complete the following questionnaire, and we will contact you shortly.

BASIC INFORMATION

Full Name

Email Address

Contact Number

Current Address

Date of birth

Gender

Best time and day to reach you

Best way to contact you

Occupation

Current Weight

MEDICAL HISTORY

Do you smoke?

Yes No

Do you drink?

Yes No

Allergies

What type of cancer do you have and at what stage?

When were you diagnosed?