Patient Form - O-xygen

Patient Information Form

Patient Name(Required)

Email(Required)

Phone(Required)

DOB(Required)

AGE(Required)

GENDER(Required)

WEIGHT (LBS)(Required)

Please enter a number greater than or equal to 0.

HEIGHT (FT)(Required)

Please enter a number greater than or equal to 0.

Address

Street Address

City

State / Province / Region

ZIP / Postal Code

SPECIFICS

ORIGINAL DIAGNOSIS

CLASSIFICATION

STAGE

DATE OF ORIGINAL DIAGNOSIS

PREVIOUS TREATMENTS RECEIVED

SURGERY DATE

CHEMOTHERAPY (AGENTS AND DATES)

RADIATION (DOSE, SITE AND DATE)

HORMONE THERAPY (AGENTS AND DATES)

OTHERS (TYPES AND DATES)

RESULTS AND SIDE EFFECTS FROM ANY OF THE ABOVE THERAPIES

PRESENT SITUATION OF YOUR DISEASE, STAGE, COMPLICATIONS, SYMPTOMS

RESENT INTERVENTIONS OR MEDICAL PROCEDURES

CURRENT TREATMENTS AND MEDICATIONS

MOST RECENT LABORATORY REPORTS (PLEASE, ATTACH RESULTS IF AVAILABLE)

MOST RECENT LABORATORY REPORT

Accepted file types: pdf, Max. file size: 256 MB.

MOST RECENT IMAGING STUDY REPORTS (PLEASE, ATTACH IF AVAILABLE)

MOST RECENT IMAGING STUDY REPORT

Accepted file types: pdf, Max. file size: 256 MB.

PRESENT STATUS PERFORMANCE (ECOG OR KARNOFSKY SCORE)

ADDITIONAL INFORMATION COMMENTS

Signature

O-xygen is a pristine environment clinic that integrates regenerative biomedicine with a holistic approach.

4558 Agua Caliente Blvd Tijuana, Baja California 22420

(619) 946-2586

info@o-xygen.com

(664) 686-5061

+52 (664) 686-5484