Candidate Form

1. Demographic Information

Patient First Name

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Patient Last Name

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Date of Birth

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Age

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Marital Status

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Gender

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Height

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Weight

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Breast Size

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Address

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Apt or Unit

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City

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State

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Zip Code

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2. Employer Information

Name of Employer

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Mobile Number

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Name and Phone Number of Emergency Contact

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3. Primary Insurance

Name of Subscriber

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Insurance Company

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Date of Birth

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SubscriberNumber

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Do you have secondary insurance?

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If Yes

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Name of Subscriber

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Insurance Company

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SubscriberNumber

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4. Date of breast diagnosis

Date of Mastectomy

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Date of Lumpectomy

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Location of breast diagnosis

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Have you had positive genetic testing

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Have you had chemotherapy?

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If yes, date of last treatment

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Have you had Radiation?

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If yes, date of last treatment

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Location

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5. List any major illness along with dates

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6. List past surgeries and dates

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7. Do you have a history of bleeding or clotting disorders?

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8. Family history of cancer. List any blood relatives with a cancer diagnosis, please include type of cancer.

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9. List all current medications

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How did you hear about Dr Hugo St Hilaire?

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If yes, please list:

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10. Are you currently or ever have been a smoker?

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If you were a previous smoker, when did you stop?

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