Golden State Cancer Radiation Center Golden State Cancer Centers Woodland Hills West Hills Location Contact Golden State Cancer Radiation Centers
Golden State Cancer Centers - Cancer Radiation Therapy & Treatment | Serving West Hills - Woodland Hills - Los Angeles & Ventura County

818-449-2700
21300 Erwin Street
Woodland Hills, CA 91367
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  • Caring Cancer Radiation Oncology Center

    People who care, treatment that works

  • State-Of-The-Art Cancer Radiation Treatment Center

    Combining State-Of-The-Art technology with the best physicians

  • Advanced Cancer Oncology Radiation Therapy

    Let our team of experts help you to live a healthy life, CANCER FREE

  • Los Angeles Cancer Radiation Treatment Center

    Fighting cancer precisely

  • Successful Cancer Radiation Treatment

    Offering individualized treatment plans, and the highest quality of care to patients

  • Advanced Radiation Cancer Center

    Advanced technolgies, enhanced patient care

  • Comprehensive Cancer Radiation Therapy of Los Angeles

    Providing specialized patient services such as: Support Groups & Patient Navigator to be with you every step of the way!


Golden State Cancer Centers


Patient Medical History Form

PATIENT INFORMATION

First Name:
Last Name:
Street Adress:
City:
State:
Zip:
SS Number (optional):
Male Female
Marital Status:
Home Phone:
Cell:
Work:
DIAGNOSIS INFORMATION
What Type of Cancer Do You Have?
Have You Ever Had Another Type of Cancer?
RELATIVE INFORMATION (SPOUSE/SIGNIFICANT OTHER)
First Name:
Last Name:
DOB:
Home Phone:
Cell:
Work:
ALTERNATE/EMERGENCY CONTACT INFORMATION (OTHER THAN SPOUSE/SIGNIFICANT OTHER)
First Name:
Last Name:
Street Adress:
City:
State:
Zip:
Home Phone:
Cell:
Work:
REFERRING PHYSICIAN
Oncologist Urologist Ear, Nose & Throat GYN
First Name:
Last Name:
Street Adress:
Suite #:
City:
State:
Zip:
Office Phone:
Office Fax:
PRIMARY CARE PHYSICIAN
First Name:
Last Name:
Street Adress:
Suite #:
City:
State:
Zip:
Office Phone:
Office Fax:
SURGEON OR OTHER PHYSICIAN
First Name:
Last Name:
Street Adress:
Suite #:
City:
State:
Zip:
Office Phone:
Office Fax:
OTHER PHYSICIAN
Gastroenterologist Neurosurgeon Dentist Thoracic Surgeon
Vascular Surgeon Pain Specialist Dermatologist Other:
First Name:
Last Name:
Street Adress:
Suite #:
City:
State:
Zip:
Office Phone:
Office Fax:
WOULD YOU LIKE US TO SEND RECORDS TO ANY OTHER DOCTOR?
Yes    No
M.D. Name:
Phone:
City:
HISTORY OF MEDICAL PROBLEMS
1:
2:
3:
4:
5:
6:
HISTORY OF SURGERIES
1:
Date:
2:
Date:
3:
Date:
4:
Date:
5:
Date:
6:
Date:
CURRENT MEDICATIONS
Please list all medications or bring in a current list
Drug Allergies:
Yes Cancer Center No
Name:
Strength:
Taken How Often:
Name:
Strength:
Taken How Often:
Name:
Strength:
Taken How Often:
Name:
Strength:
Taken How Often:
Name:
Strength:
Taken How Often:
Name:
Strength:
Taken How Often:
List Any Others:
Pharmacy Name:
City:
Phone:
FAMILY HISTORY OF CANCER
Relationship:
Type of Cancer:
Is This Person Alive?
Yes Radiation Therapy No
Relationship:
Type of Cancer:
Is This Person Alive?
Yes Advanced Radiation Therapy No
Relationship:
Type of Cancer:
Is This Person Alive?
Yes Radiation Therapy No
Relationship:
Type of Cancer:
Is This Person Alive?
Yes Golden State Cancer Center No
Relationship:
Type of Cancer:
Is This Person Alive?
Yes San Fernando Valley Cancer Center No
GENERAL HEALTH
Whom Do You Live With?
Do You Have Children?
No California Cancer Center Yes Southern California Cancer Center   # of Males Advanced Cancer Center   # of Females
What Work Do You Do?
Do You Climb Stairs At Home?
No Advanced Radiation Therapy Yes Radiation Therapy   # Of Stairs
Do You Smoke?
No Golden State Cancer Center Yes Cancer   Per Day Cancer Center   # Of Years
If You Quit Smoking, When?
How Much Did You Smoke?
How Many Years?
Do You Drink?
No Golden State Cancer Center Yes Golden State Cancer Center   Per Day Golden State Cancer Center   # Of Years
If You Quit Drinking, When?
ARE YOU EXPERIENCING...
Change In Weight?
No Cancer Center Yes Radiation
Change in Energy Level?
No Radiation Yes Cancer Patient
Change in Vision?
No Cancer Therapy Yes Cancer Treatment
Change in Hearing?
No Cancer Yes Successful Cancer Treatment
Change in Mouth?
No Cancer Treatment Yes Radiation
Change in Breathing?
No Radiation Therapy Yes Radiation Cancer Therapy
Fevers?
No Golden State Yes Cancer Center
Night Sweats?
No California Cancer Center Yes Southern California Cancer Center
Nausea?
No Cancer Center Yes Cancer Treatment
Vomiting?
No Cancer Therapy Yes Radiation Treatment
Stomach Pain?
No Radiation Therapy Yes Cancer
Cough?
No Golden State Cancer Center Yes Golden State Cancer Center
Coughing Blood?
No Golden State Cancer Center Yes Golden State Cancer Center
Chest Pain?
No Golden State Cancer Center Yes Golden State Cancer Center
Back Pain?
No Golden State Cancer Center Yes Golden State Cancer Center
Constipation?
No Golden State Cancer Center Yes Golden State Cancer Center
Diarrhea?
No Golden State Cancer Center Yes Golden State Cancer Center
Blood in Stool?
No Golden State Cancer Center Yes Golden State Cancer Center
Change in Stool Color?
No Golden State Cancer Center Yes Golden State Cancer Center
Change in Urination?
No Golden State Cancer Center Yes Golden State Cancer Center
Blood in Urine?
No Golden State Cancer Center Yes Golden State Cancer Center
Swelling in Legs?
No Golden State Cancer Center Yes Golden State Cancer Center
Swelling in Arms?
No Golden State Cancer Center Yes Golden State Cancer Center
Weakness in Legs?
No Golden State Cancer Center Yes Golden State Cancer Center
Weakness in Arms?
No Golden State Cancer Center Yes Golden State Cancer Center
Numbness in Legs?
No Golden State Cancer Center Yes Golden State Cancer Center
Numbness in Arms?
No Golden State Cancer Center Yes Golden State Cancer Center
Seizure?
No Golden State Cancer Center Yes Golden State Cancer Center
Confusion?
No Golden State Cancer Center Yes Golden State Cancer Center
FEMALES ONLY
Are You Experiencing...
Change in Breasts?
No Golden State Cancer Center Yes Golden State Cancer Center
Pain in Breasts?
No Golden State Cancer Center Yes Golden State Cancer Center
Change in Breast Skin?
No Golden State Cancer Center Yes Golden State Cancer Center
Blood from Nipples?
No Golden State Cancer Center Yes Golden State Cancer Center
Vaginal Bleeding?
No Golden State Cancer Center Yes Golden State Cancer Center
Vaginal Discharge?
No Golden State Cancer Center Yes Golden State Cancer Center
Have You Had Any...
Mammograms?
No Golden State Cancer Center Yes Golden State Cancer Center
Pap Smears?
No Golden State Cancer Center Yes Golden State Cancer Center
Periods?
No Golden State Cancer Center Yes Golden State Cancer Center
Pregnancies?
No Golden State Cancer Center Yes Golden State Cancer Center
Miscarriages?
No Golden State Cancer Center Yes Golden State Cancer Center
Abortions?
No Golden State Cancer Center Yes Golden State Cancer Center