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Confidential Cancer Patient Questionnaire
Please take care to accurately complete the online application.

First Name:
Last Name:
Your Email:
Today's Date:
Your D.O.B.:
Current Age:

Referring Physician:
Referring physican's telephone or fax number, or email:
Reason for seeing Dr. Oktay:

What was the first day of your last period?
Date last PAP smear?
Age at time of first period?
Are your periods regular? (f irregular, please describe):
How many days between periods?
How many days do you bleed?
Your height:
Your weight:
Do you have a partner/boyfriend?
Type of cancer you were diagnosed with:
Date diagnosed:
Age when diagnosed:
Is cancer in your family history?
Who else in your family has been affected, and what kind of cancer?
Did you have surgery for your cancer?
Date of your surgery:
Type of surgery:

PATHOLOGY REPORT
Please provide the following information from your pathology report. If your pathology report is not available, please arrange to fax a copy to: 212-994-4499.
Stage:
Size:
Histological grading:
Histological type:
Nuclear grading:
Estrogen rec:
Mitotic index:
Progesterone rec:
Vascular invasion?
Her 2 neu rec:
Lymph node:

If you were tested for BRCA 1 or 2, what was the result?
If you have cancer in your family, have those members been tested for BRCA 1 or 2?
Have you ever received chemotherapy and/or radiotherapy for cancer?
If yes, describe the treatment?
What was the treatment dosage?
Treatment date?
Treatment duration?

Ever taken Zoladex (GnRh analogue) while you were receiving chemo- or radiotherapy?
If yes, what was the date?
What was the duration?

Has there ever been a change in the regularity of your periods after chemotherapy and/or radiotherapy?
Ever been diagnosed as menopausal after chemo- and/or radiotherapy?
Are you scheduled to have chemo- and/or radiation in the near future?
If yes, provide the name and dose of the drug or radiation treatment
Expected duration of future treatment?
Ever used oral contraceptives?
If yes, how long?

Are you allergic to any medications?
List which drugs and your reactions:
Are you allergic to shellfish, seafood or iodine?

This report was reviewed by Dr. Oktay:

Confidential Cancer Patient Questionnaire Please take care to accurately complete the online application.

Confidential Cancer Patient Questionnaire
Please take care to accurately complete the online application.