Get Initial Cancer Inquiry Report Form - Public Health - Public Health Oregon

This guide provides clear instructions for filling out the Initial Cancer Inquiry Report Form online. By following the steps outlined below, users can ensure accurate and complete information submission.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the name of the patient in the designated field. This is the full name as it appears on legal documents.
3. Provide the name of the person giving the information. Ensure that this is someone who knows the patient well.
4. Indicate the relationship to the patient in the respective section, using a neutral term.
5. Enter the date of birth of the patient in the format of month/day/year followed by the patient's age at their last birthday.
6. Fill in the address of the patient, ensuring it is complete for accurate records.
7. Specify the length of residence in the community, which helps in demographic analysis.
8. Select the patient's race from the provided options. This information is used for public health assessments.
9. Indicate the patient's gender in the corresponding section.
10. Document the date of diagnosis, clearly noting the month and year.
11. Provide details regarding the type of cancer, including the original cell type and affected body organs. This is crucial for accurate record-keeping.
12. Input the name and telephone number of the primary physician, ensuring it is correct for follow-up.
13. List any major health problems the patient has experienced, including all relevant medical history.
14. Outline the patient's work history, detailing occupations, industries, and lengths of employment.
15. If applicable, list any family members who have had cancer, noting their relation and the type of cancer they had.
16. Indicate if the patient currently smokes or has smoked tobacco in the past, including the number of years.
17. Note if there are any household members who currently smoke or have smoked, including the number of individuals.
18. Specify the drinking water source for the patient's residence, including whether it is municipal or well water.
19. List major hobbies practiced within the patient's residence, as this may relate to their health.
20. If there are any thoughts about what may have caused or contributed to the cancer, please provide that information.
21. Review the entire form for accuracy and completeness before final submission.
22. Once completed, you can save changes, download, print, or share the form as needed.

Complete your documents online to contribute to public health knowledge and patient care.