Home
Doctors
Neurosurgeons
Frank Culicchia, MD, FAANS
Robert Applebaum, MD
John Steck, MD, FAANS
Alan M. Weems, MD, FACS, FAANS
Carl Culicchia, MD
Neuro-oncology
Neurologists
Steven Atkins, MD
R. Charles Fiore, Jr., MD
K. David Khoobehi, MD
Michael Puente, MD
Interventional Neuroradiology
Robert Dawson, MD
Physical Medicine/Pain Management
Andrea Toomer, MD
Brian Michael Koch, MD
Stephen Rynick, MD
Hearing and Balance-Neurotology
Moises Arriaga, MD
Audiologist
Elizabeth Montgomery, Au.D., CCC-A, F-AAA
Patti St. John, Au.D., CCC-A, F-AAA
Brittany Thomas, Au.D., CCC-A, F-AAA
Nurse Practitioner
Danielle Alfortish, APRN, FNP-C
Amber Hall, FNP-C
Physician Assistant
LaShon Maggio, PA-C
Physical Therapy
Carrie Black, PT, DPT, C/NDT
Rebecca Callais, OT, LOTR
Specialties
Neurosurgery
Aneurysm
AVM: Microcatheterization
Hydrocephalus
Neurology
Migraines
Multiple Sclerosis
Parkinson’s Disease
Stroke
Carotid Artery Screening
Survivor: Sarah Abrusley
Hearing and Balance-Neurotology
Acoustic Neuroma
Cochlear Implants
Audiology
Physical Medicine / Rehabilitation
Spasticity
Baclofen Pump
Botulinum Toxin Injections
Physical Therapy
Unlocking Spasticity
Vestibular Rehabilitation for Inner Ear and Balance
Spine
Facet Injection
Lumbar Steroid Injection for Low Back Pain
Epidural Steroid Injection
Kyphoplasty
Lumbar Laminectomy for Sciatica
Mobi-C Cervical Disc Replacement
Percutaneous Discectomy
Trufuse Facet Procedure
Stenosis
Superion Vertiflex for Lumbar Spinal Stenosis
Trauma
Head Injury
Brain Tumors
Brain Tumor Second Opinion
Pilocytic Astrocytoma
Malignant Brain Tumors
Optune Brain Tumor Therapy
Are You a Candidate for Optune Glioblastoma Treatment?
Benign Tumor
Meningioma
Acoustic Neuroma
Vascular
NeuroNews
Videos
Locations
Pay Bill
Careers
Patient Portal
504.340.6976
Call us Today!
504.340.6976
Schedule an Appointment
Call Now
Home
Doctors
Neurosurgeons
Frank Culicchia, MD, FAANS
Robert Applebaum, MD
John Steck, MD, FAANS
Alan M. Weems, MD, FACS, FAANS
Carl Culicchia, MD
Neuro-oncology
Neurologists
Steven Atkins, MD
R. Charles Fiore, Jr., MD
K. David Khoobehi, MD
Michael Puente, MD
Interventional Neuroradiology
Robert Dawson, MD
Physical Medicine/Pain Management
Andrea Toomer, MD
Brian Michael Koch, MD
Stephen Rynick, MD
Hearing and Balance-Neurotology
Moises Arriaga, MD
Audiologist
Elizabeth Montgomery, Au.D., CCC-A, F-AAA
Patti St. John, Au.D., CCC-A, F-AAA
Brittany Thomas, Au.D., CCC-A, F-AAA
Nurse Practitioner
Danielle Alfortish, APRN, FNP-C
Amber Hall, FNP-C
Physician Assistant
LaShon Maggio, PA-C
Physical Therapy
Carrie Black, PT, DPT, C/NDT
Rebecca Callais, OT, LOTR
Specialties
Neurosurgery
Aneurysm
AVM: Microcatheterization
Hydrocephalus
Neurology
Migraines
Multiple Sclerosis
Parkinson’s Disease
Stroke
Carotid Artery Screening
Survivor: Sarah Abrusley
Hearing and Balance-Neurotology
Acoustic Neuroma
Cochlear Implants
Audiology
Physical Medicine / Rehabilitation
Spasticity
Baclofen Pump
Botulinum Toxin Injections
Physical Therapy
Unlocking Spasticity
Vestibular Rehabilitation for Inner Ear and Balance
Spine
Facet Injection
Lumbar Steroid Injection for Low Back Pain
Epidural Steroid Injection
Kyphoplasty
Lumbar Laminectomy for Sciatica
Mobi-C Cervical Disc Replacement
Percutaneous Discectomy
Trufuse Facet Procedure
Stenosis
Superion Vertiflex for Lumbar Spinal Stenosis
Trauma
Head Injury
Brain Tumors
Brain Tumor Second Opinion
Pilocytic Astrocytoma
Malignant Brain Tumors
Optune Brain Tumor Therapy
Are You a Candidate for Optune Glioblastoma Treatment?
Benign Tumor
Meningioma
Acoustic Neuroma
Vascular
NeuroNews
Videos
Locations
Pay Bill
Careers
Patient Portal
504.340.6976
Call us Today!
Brain Tumor Second Opinion (Pt. 2)
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»
Brain Tumor Second Opinion (Pt. 2)
Second Opinion Medical Imaging Upload - Part 2
Step
1
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8
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Patient First Name
*
Patient Last Name
*
Patient Email Address
*
File
Max. file size: 50 MB.
Agreement
Statement of Financial Responsibility
- I understand that I am responsible for payment to Culicchia Neurological Clinic, LLC for this second opinion. I understand that I am ultimately responsible for all medical expenses incurred and agreed to pay all amounts.
HIPAA Regulations
- I agree that Culicchia Neurological Clinic may request and use my prescription medication history from other healthcare providers or third-party pharmacy benefit payors for purposes of clarification of medical history. The following signature acknowledges that I have received notification of my privacy rights concerning the use and disclosure of protected health information as defined by the privacy regulations.
Signature
*
I agree.
Today's Date
MM slash DD slash YYYY
Neuro-Oncology Review of Systems
Are you currently on chemotherapy?
*
Yes
No
What were the last dates that you had chemotherapy?
By Mouth:
MM slash DD slash YYYY
By Vein:
MM slash DD slash YYYY
Do you use a medication to thin your blood?
*
Yes
No
What medication?
Do you take aspirin every day?
*
Yes
No
Have you had any hospitalizations or visits to the emergency department since your last visit?
*
Yes
No
What day(s)
What was the reason for your emergency department visit and/or hospitalization?
Review of Systems (1 of 2)
Please place a check in front of (or circle) any of the following symptoms that you had in the months leading up to your first visit with us, or that you’ve had in the time since we’ve last seen you. If you have not had any symptoms in the category, please place a check in front of (or circle) “No problems”.
Constitutional:
*
Fever
Chills
Sweats/Night Sweats
Generalized Weakness
Fatigue
Recent unexpected weight loss
Recent unexpected weight gain
Decreased appetite
Excessive thirst
Heat intolerance
Cold intolerance
Excessive thirst
No Problems
Glands/Lymph nodes:
*
Lumps in the neck
Swollen glands in the neck
Swollen glands near the collarbone/in the upper chest
Swollen glands in the armpit
Swollen glands in the groin/inner thigh
No Problems
Skin:
*
Itching
Rash
Mole change
Open sores that won’t heal
Dry skin
Flaky skin
Skin discoloration
Eyes:
*
Blurred vision
Double vision
Right eye vision loss
Left eye vision loss
Right eye partial visual field loss
Left eye partial visual field loss
Loss of part of the visual field in both eyes
Yellowing of the whites of the eyes
No Problems
Ears:
*
New difficulty hearing
Worsening of pre-existing hearing difficulty
Ringing/buzzing in the ears (tinnitus)
Right Ear Pain
Left Ear Pain
Right drainage from the ear
Left drainage from the ear
Dizziness
Vertigo
Unsteadiness (disequilibrium)
Balance difficulties
No Problems
Nose:
*
Stuffy nose
Frequent colds
Hay fever
Sinus trouble
Frequent nosebleeds
No problems
Mouth and Throat:
*
Frequent sore throats
Pain near teeth or mouth
Sores in the mouth
Hoarseness/Voice change
Neck pain
Difficulty swallowing Solids
Difficulty swallowing Liquids
Difficulty swaowing Pills/Medications
No Problems
Chest (lungs and heart):
*
Chest pain
Cough
I am “bringing anything up” with the cough
Shortness of breath with activity only
Shortness of breath with activity, and at rest
Shortness of breath suddenly while at rest
Shortness of breath lying down only
Shortness of breath randomly
Wheezing
Palpitations/heart beating out of rhythm
Heart beating too fast
Pain in the ribs/chest/side when taking a breath
No Problems
You are "bringing something up" with your cough. Is it:
*
Clear/whitish
Green/yellow
Bloody *”Rusty” colored
Foul smelling
Gastrointestinal (GI):
*
Heartburn/Acid Reflux
Ulcers
Abdominal pain
Nausea
Vomiting
Diarrhea
Constipation
Loss of bowel control
Blood in stool
Black/”tarry” stool
Hemorrhoids
Pale/”clay” colored stool
Jaundice/yellow skin
No Problems
Genitourinary (GU):
*
Frequent/increased frequency of urination
”Excessive” urination
Urinary urgency
Increased urination at night
Difficulty initiating urination *Decrease “strength” of urine stream
Painful urination
Blood in the urine
Loss of bladder control
No Problems
Musculoskeletal:
*
Joint pain
Joint stiffness
Muscle pain
Muscle stiffness
Muscle weakness
Back pain
Swelling in right foot
Swelling in left foot
Pain in right foot
Pain in left foot
Swelling in right leg
Swelling in left leg
Right leg pain
Left leg pain
Pain behind the right knee
Pain behind the left knee
Pain and/or swelling associated with red/painful skin
Pain and/or swelling associated with change in skin temperature
Pain with skin temperature that is warm to touch
Pain with skin temperature that is cool to touch
No Problems
Male Reproductive:
Sexual dysfunction
Difficulty achieving or maintaining erections
Difficulty ejaculating
Testicular pain
Testicular swelling
No Problems
Female Reproductive:
Sexual Dysfunction
Painful intercourse
Vaginal dryness
Pelvic pain
Loss of menses/period
Abnormal bleeding
No Problems
Review of Systems (2 of 2)
Please place a check in front of (or circle) any of the following symptoms that you had in the months leading up to your first visit with us, or that you’ve had in the time since we’ve last seen you. If you have not had any symptoms in the category, please place a check in front of (or circle) “No problems”.
Emotional:
*
Anxiety/nervousness
Increased pre-existing anxiety/nervousness
Depression
Worsened pre-existing depression
Irritability
Increased pre-existing irritability
Personality changes
Mood swings
Difficulty falling asleep
Difficulty staying asleep
Suicidal thoughts
Homicidal thoughts
No Problems
Average hours of sleep per night:
Bedtime
Wake time
Hematologic:
*
Easy bruising
Easy bleeding
Frequent/re-occurring infections
No Problems
Allergies:
*
Hay fever/environmental allergies
Dust sensitivity
Mold allergies
Food sensitivity
Food intolerance
New medication allergies
New chemical sensitivity
No Problems
Thought Processes:
*
Changes in memory
Changes in concentration
Difficulty coming up with words you want to say Difficulty understanding what others are saying to you
No Problems
Nerves of the face and head:
*
Face numbness
Change in facial appearance
No Problems
Strength:
*
Weakness in right hand/arm, foot/leg
Weakness in left hand/arm, foot/leg
Weakness in whole right side of the body
Weakness in whole left side of the body
Weakness in both arms
Weakness in both legs
Difficulty climbing stairs
Difficulty getting out of chairs
Difficulty reaching above your head
No Problems
Sensation:
*
Burning
Aching
Tingling
Numbness
Decreased sensation
Experience pain sensation with something that shouldn’t be painful
Please indicated body part(s) and side of the body affected:
Coordination:
*
Change in coordination
Reaching out and knocking things over
Difficulty with tasks requiring manual dexterity (such as buttoning buttons or using utensils to eat)
Difficulty walking
Bumping into doorways
Bumping into furniture
Falls
No Problems
How many falls?
*
Headaches:
*
Brief
Long lasting
Worse when lying down
Worse when standing up
Worse if bearing down (such as when lifting something, bending over, or when having a bowel movement)
No Problems
Seizures:
*
Have had a seizure
Lost consciousness with the seizure
No Problems
How often do you have seizures?
When was the last time you had a seizure?
Do you experience:
*
Butterflies in your stomach (like being on a rollercoaster)
Unexpected foul smells (especially burning rubber or burning metal)
Feelings of déjà vu (unexpected familiarity with a
situation, place, or events)
Involuntary movements of face, arms, hands, legs, other body parts
Staring spells
Have awakened to find that you had bitten your tongue or lost control of your bowel or bladder
No Problems
Other:
*
”Electric shocks” in the neck when looking down
Sudden sharp pain in neck
Sudden sharp pain in back
Sudden sharp pain in shoulders
Sudden sharp pain in arms
Sudden sharp pain in hips
Sudden sharp pain in legs
Pain, numbness, or other sensory change that starts in the middle of your back and travels around to the middle of your front in a “band-like” fashion
No Problems
Neuro-Oncology Patient History
Name of referring physician:
*
Reason for visit:
*
What type of work do you do?
Are you currently disabled?
*
Yes
No
Current Medication List
(Including non-prescription medications, over the counter supplements, etc)
Medication Name
Dose (mg)
Times per day
Month/Year started taking
Allergies(medications, dyes, foods, other):
Pharmacy Information
Pharmacy Name:
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Past Medical History:
High Blood Pressure
Migraine Headaches
Anemia
Alcohol Abuse
Heart Disease
Seizure Disorder
Blood Clots
Mental Illness
Diabetes
Dementia
Bleeding Disorder
Drug Abuse
High Cholesterol
Arthritis
Osteoporosis
Depression
Stroke
Rheumatoid Arthritis
Glaucoma
Cancer
Kidney Disease
Bronchitis
Asthma
Thyroid Disease
Acid Reflux/Ulcer
Liver disease
HIV/AIDS
Leukemia/Lymphoma
Gout
Aneurysm
Vascular Disease
Macular Degeneration
Allergies
Anxiety
COPD (lung disease)
Lupus
Tuberculosis (TB)
Muscle disease
Nerve disease
Neuropathy
Alzheimer’s
Emphysema
Hepatitis
Other
Other:
Gynecological History
(For Female Patients Only):
Do you still have menstrual periods?
Yes
No
Last menstrual period:
MM slash DD slash YYYY
Why not?
Ablation
Injection
Breastfeeding
Intrauterine Device
Chemotherapy
Postmenopausal
Hormonal Contraception
Post-Partum
Hormone Suppressed
Pregnant
Hysterectomy
Radiation
Implant
Don’t Know
Other
Estimated Delivery Date:
MM slash DD slash YYYY
Other:
Previous Hospitalizations and/or Surgeries:
Year
Illness or Operation
Year
Illness or Operation
Have you ever had a transfusion or been exposed to other blood products?
*
Yes
No
Please describe the circumstances
Cancer History
*
Please check any previous and/or current cancers you have been diagnosed with
Bladder Cancer
Esophageal Cancer
Pancreatic Cancer
Bone Cancer
Leukemia
Prostate Cancer
Brain Cancer
Lung Cancer
Skin Cancer
Breast Cancer
Lymphoma
Small Intestine Cancer
Cervical Cancer
Ovarian Cancer
Stomach Cancer
Colon Cancer
Uterine Cancer
Other
Previous Cancer Treatments
Type of Cancer
Surgery Treatment
(what kind?)
Chemotherapy
(what agents?)
Radiation
(to where?)
Hormonal therapy
No
Yes
Other
(specify)
Other Cancer Treatments?
Yes
No
Type of Cancer
Surgery Treatment
(what kind?)
Chemotherapy
(what agents?)
Radiation
(to where?)
Hormonal therapy
No
Yes
Other
(specify)
Other Cancer Treatments?
Yes
No
Type of Cancer
Surgery Treatment
(what kind?)
Chemotherapy
(what agents?)
Radiation
(to where?)
Hormonal therapy
No
Yes
Other
(specify)
Have you had a pneumonia vaccination?
*
Yes
No
Have you had a shingles (herpes zoster) vaccination?
*
Yes
No
Have you had a flu shot?
*
Yes
No
Do you have an Advanced Directive (Living Will)?
*
Yes
No
Social
Marital Status:
*
Divorced
Legally Separated
Married
Significant Other
Single
Widowed
Unknown
Other
Other
I currently Live:
*
Alone
With Family
With Friends
With Significant
Other
Other
Do you have children?
*
Yes
No
Ages:
What is your occupation?
*
Do you drink caffeinated beverages?
*
Yes
No
What type of beverage(s)?
Coffee
Tea
Soda
Energy Drinks
Other
Other
How much do you drink per day?
*
Tobacco, Alcohol, and Drug Use History
Check one of the following about smoking tobacco:
*
Never smoked
Former smoker
Smoke sometimes, but not daily
Smoke every day
Exposed to second hand smoke
How many packs do/did you smoke per day?
How many years did you smoke/have you smoked?
When did you quit?
Do you use “smokeless tobacco”?
*
Never used
Former user
Current user
Type?
Snuff
Chew
When did you quit?
Are you ready to quit smoking and/or using smokeless tobacco?
*
Yes
No
Alcohol History
Do you ever drink alcohol?
*
Yes
No
Please indicate the quantity per week of each:
Glasses of wine
Cans/bottles of beer
Shots of liquor
Drinks containing 0.5 oz of alcohol
Illicit/Recreational Drug Use History
Do you use drugs?
*
Yes
No
How many times per week?
*
What type(s) of drugs do you use?
*
Sexual History
Are you sexually active?
*
Yes
No
Not Currently
If yes, is/are your partner(s):
Male
Female
Both
Type of birth control/protection currently used:
*
Not having sex (abstinence)
Condom
IUD (Intrauterine device)
Partner Vasectomy
Oral Contraceptive Pill
Patch
Post-menopausal
Tubal Ligation
Injection
Vasectomy
None
Other
Other:
Family History
Have any of your relatives had:
Alcohol Abuse
Father
Mother
Sibling
Child
Grandmother
Grandfather
Alzheimer’s/Dementia
Father
Mother
Sibling
Child
Grandmother
Grandfather
Anemia
Father
Mother
Sibling
Child
Grandmother
Grandfather
Anesthesia Problems
Father
Mother
Sibling
Child
Grandmother
Grandfather
Aneurysm
Father
Mother
Sibling
Child
Grandmother
Grandfather
Arthritis
Father
Mother
Sibling
Child
Grandmother
Grandfather
Bleeding Disorder
Father
Mother
Sibling
Child
Grandmother
Grandfather
Blood Clots
Father
Mother
Sibling
Child
Grandmother
Grandfather
Breast Cancer
Father
Mother
Sibling
Child
Grandmother
Grandfather
Colon Cancer
Father
Mother
Sibling
Child
Grandmother
Grandfather
Depression
Father
Mother
Sibling
Child
Grandmother
Grandfather
Diabetes
Father
Mother
Sibling
Child
Grandmother
Grandfather
Drug Abuse
Father
Mother
Sibling
Child
Grandmother
Grandfather
Glaucoma
Father
Mother
Sibling
Child
Grandmother
Grandfather
Heart Disease
Father
Mother
Sibling
Child
Grandmother
Grandfather
High Blood Pressure
Father
Mother
Sibling
Child
Grandmother
Grandfather
High Cholesterol
Father
Mother
Sibling
Child
Grandmother
Grandfather
Kidney Disease
Father
Mother
Sibling
Child
Grandmother
Grandfather
Leukemia
Father
Mother
Sibling
Child
Grandmother
Grandfather
Lung Cancer
Father
Mother
Sibling
Child
Grandmother
Grandfather
Lymphoma
Father
Mother
Sibling
Child
Grandmother
Grandfather
Melanoma
Father
Mother
Sibling
Child
Grandmother
Grandfather
Mental Illness
Father
Mother
Sibling
Child
Grandmother
Grandfather
Migraine Headache
Father
Mother
Sibling
Child
Grandmother
Grandfather
Multiple Myeloma
Father
Mother
Sibling
Child
Grandmother
Grandfather
Osteoporosis
Father
Mother
Sibling
Child
Grandmother
Grandfather
Ovarian Cancer
Father
Mother
Sibling
Child
Grandmother
Grandfather
Pancreatic Cancer
Father
Mother
Sibling
Child
Grandmother
Grandfather
Rheumatoid Arthritis
Father
Mother
Sibling
Child
Grandmother
Grandfather
Sarcoma
Father
Mother
Sibling
Child
Grandmother
Grandfather
Seizure Disorder
Father
Mother
Sibling
Child
Grandmother
Grandfather
Stroke
Father
Mother
Sibling
Child
Grandmother
Grandfather
Other (specify):
Patient Provider Information
Family physician:
Name
Specialty
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
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Guinea-Bissau
Guyana
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Heard and McDonald Islands
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Ireland
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Libya
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Macedonia
Madagascar
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Martinique
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Mayotte
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Montenegro
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Namibia
Nauru
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New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
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Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
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Russia
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Virgin Islands, U.S.
Wallis and Futuna
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Country
Phone
Fax
Neurosurgeon:
Name
Specialty
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
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Dominican Republic
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Egypt
El Salvador
Equatorial Guinea
Eritrea
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Ethiopia
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Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
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Greenland
Grenada
Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
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Heard and McDonald Islands
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Jordan
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Latvia
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Liberia
Libya
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Macau
Macedonia
Madagascar
Malawi
Malaysia
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Mali
Malta
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Martinique
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Mayotte
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Montserrat
Morocco
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Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
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Sint Maarten
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Slovenia
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Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
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Sudan
Suriname
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Sweden
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Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
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Venezuela
Vietnam
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Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
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Zimbabwe
Åland Islands
Country
Phone
Fax
Radiation Oncologist:
Name
Specialty
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
Fax
Medical Oncologist:
Name
Specialty
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
Fax
Other
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