CANCER CENTER FOR HEALING
CANCER CENTER FOR HEALING
MEDICAL QUESTIONNAIRE
Please fill out the medical questionnaire below. Once completed, please save and return as an attachment by
email to . Once Dana receives the information she will contact you to
arrange a consultation with one of our Cancer Team Doctors. After the consult we will customize a
treatment plan.
INSURANCE INFORMATION: Please provide Cancer Center For Healing with a front and back copy of your
insurance card so we can verify coverage prior to your consultation.
NOTE•: In lieu of medical records, please send all pertinent scan reports (MRI, Ultrasounds, PET) and all
pertinent labs taken in the last 3 months to We do not accept records on
CDs, please provide us with a word or PDF document.
Patient Name: Jeffrey Epstein
DOB: Jan. 20, 1953
Age: 63
Sex: Male
Home Phone:
Cell Phone:
Who do we contact to set up the
consultation (name & hone number): Lesley-
Email:
Home Address:
Street, City, State & Zip 9 East 71s, Street
New York, New York 10021
Date of Cancer Diagnosis: Na
Type of Cancer (Pathology Diagnosis): N/A
6 Hughes, Suite 12081 Irvine, CAI 92618
www.cancercenterforhealing.com
EFTA00295979
CANCER CENTER FOR HEALING
Cancer Stage:
N/A
Have you received Chemo? What
dates did you receive treatment?:
N/A
Have you received Radiation? What
dates did you receive treatment?:
N/A
Have you had surgery to treat your
cancer? What date(s) did you have
the surgery(s) on? N/A
Any Complications from previous
treatments?:
N/A
Date of last bloodwork: N/A
Date of last PET Scan: N/A
Therapies currently receiving for
psychological/emotional wellbeing:
N/A
Father's medical history: Bladder
6 Hughes, Suite 120B I Irvine, CA I 92618
www.cancercenterforhealing.com
EFTA00295980
CANCER CENTER FOR HEALING Mothers medical history:
N/A
Family medical history:
N/A
Do you have a history of smoking or
drinking? no
Have you ever been hospitalized?
What was your diagnosis? What
dates were you in the hospital? N/A
What is your dental history? Any
major procedures
N/A
Are you in pain?: N/A
Specify type of pain on a scale from
1 to 10: N/A
Pain medication type and dosage: N/A
When do you plan to start treatment
with Cancer Center For Healing?: N/A
How did you hear about Cancer Friend who is a doctor Center For Healing?:
6 Hu hes, Suite 120B Irvine, CA 92618
www.cancercenterforhealing.com
EFTA00295981
CANCER CENTER FOR HEALING
Additional information we should N/A know:
6 Hu hes, Suite 120B Irvine CA 92618
www.cancercenterforhealing.com
EFTA00295982