Oncology Intake Form

The Oncology Intake Form is purpose-built for cancer care practices, capturing the detailed oncologic history that oncologists need for treatment planning and continuity of care. This template collects patient demographics alongside a comprehensive cancer history covering primary diagnosis (site, histology, stage, grade, molecular markers), date of diagnosis, prior treatments received (surgery, chemotherapy, radiation, immunotherapy, targeted therapy, hormonal therapy), treatment responses, and current disease status. The symptom assessment section screens for cancer-related symptoms including pain, fatigue, nausea, appetite changes, weight loss, neuropathy, and cognitive changes.

Designed for medical oncology, radiation oncology, surgical oncology, and comprehensive cancer centers, this form includes sections for prior pathology and imaging results, current and completed clinical trial participation, genetic testing and counseling history (BRCA, Lynch syndrome, hereditary cancer panels), and a thorough oncologic medication list covering chemotherapy agents, targeted therapies, immunotherapy, supportive medications (antiemetics, growth factors, pain management), and supplements. The psychosocial screening section captures distress level, caregiver information, advance directive status, and supportive care needs.

All fields are HIPAA-compliant and optimized for the oncology workflow. The multi-page format allows patients to document their cancer journey comprehensively before the consultation, including treatments received at other facilities. This pre-visit data collection is especially valuable in oncology where patients often have complex, multi-modality treatment histories that span multiple providers and institutions.