WhatsApp: +237 652 269 648（https://wa.me/237652269648） • +237 689 749 717（https://wa.me/237689749717） • Doctor on Call / WhatsApp: +237 682 978 661（https://wa.me/237682978661）
Print / Save as PDF
One-Page Patient Questionnaire
Please complete and bring with you to your appointment.
Full name
Date of birth / Age
Telephone
City / Region / Country
Reason for Visit
☐ New cancer diagnosis
☐ Suspected cancer / abnormal test
☐ Second opinion
☐ Follow-up / surveillance
☐ Treatment consultation
☐ Other: __________________
Current Problem
Main diagnosis or symptoms:
When did this problem begin?
Previous Cancer Care
Previous biopsy/pathology? ☐ Yes ☐ No
Previous surgery? ☐ Yes ☐ No
Previous chemotherapy? ☐ Yes ☐ No
Previous radiotherapy? ☐ Yes ☐ No
Where and when?
Medical & Family History
Other major medical conditions or medicines: