CSS New Client Intake Form

1
Full Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Month
Day
Year
3
Mailing address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
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
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
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
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Gender
Male
Female
Non-binary
Other
5
Phone Number* This field is required.Please provide your BEST phone number here.
Area Code
Phone Number
6
Phone MessagesCan we leave a message at the phone number listed above?
YESNO
7
Email* This field is required.Please provide your BEST email address here
example@example.com
Confirm Email
8
Mailing List* This field is required.Can we add your e-mail to our mailing list? Your email will never be sold or shared.
YESNO
9
Emergency Contact Information* This field is required.
10
What is your Cancer Diagnosis?* This field is required.Please include as much information as you can regarding your diagnosis. (Type of cancer, location, staging, current and past treatments including surgery, chemotherapy regime, radiation therapy or other types of therapies.)
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Ok
Ok
11
Tell us about your health care team.
Primary Care Physician
Surgeon
Medical Oncologist
Radiation Oncologist
Other Physicians
12
What are the main reasons you are seeking services with CSS?* This field is required.If you have more to say, there will be a chance to write more at the end of this form.
Pain
Lymphedema or swelling of extremity
Decreased range of motion
Fatigue
Nausea
Depression or anxiety
Weight changes
Stress
Neuropathy
Other
13
Please list any known allergies* This field is required.Include drug and environmental allergies
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Ok
14
Please list your current medications & supplements* This field is required.Include chemo agents, prescription medications, over the counter medications, vitamins, herbs, supplements
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Ok
15
Do you have any of the following health conditions?
Arthritis
Asthma
Autoimmune Disorders (e.g. lupus, rheumatoid arthritis)
Bowel Disorders
Dementia / Alzeihmers
Depression
Diabetes
Heart Attack
High Blood Pressure
High Cholesterol
Low Blood Pressure
Mental Illness
Muscular Dystrophy
Obesity
Osteoporosis
Osteoporosis
Skin Disorders
Stroke, TIA
Thyroid Over Active
Thyroid Under Active
None
Other
16
Do you have any medical devices?* This field is required.This includes implanted ports, catheters, prostheses, joint replacements, orthopedic hardware, etc
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Ok
17
How would you rate your current level ...
Energy and Vitality
Overall Health
Poor
Fair
Good
Excellent
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Poor
Fair
Good
Excellent
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Energy and Vitality
Overall Health
Poor
Fair
Good
Excellent
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Poor
Fair
Good
Excellent
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18
How would you rate your current level of...* This field is required.
Stress
None
Mild
Significant
Overwhelming
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Stress
None
Mild
Significant
Overwhelming
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19
Please describe your current diet.* This field is required.Give an example of your usual breakfast, lunch and dinner, and any snacks.
20
Do you exercise?30 minutes or more of activity that raises your heart rate, such as a vigorous walk, run, aerobics, swimming, weight training, yoga/pilates, sports, dance, etc
Never
1-2 times a week
3-4 times a week
5-6 times a week
Everyday
21
Please list the types of exercise you do regularly
22
How many glasses of water do you drink in a day?8 oz glass
23
Do you smoke or use tobacco?
YESNO
24
How much tobacco do you use per day?
25
Do you use any marijuana products?THC-containing products only, such as smoked marijuana or edibles
Please Select
Please Select
Yes, daily or almost daily
Yes, frequently
Yes, rarely
No, never
26
Do you use any other recreational drugs?
Please Select
Please Select
Yes, frequently
Yes, rarely
No, never
27
Do you drink alcohol?
YESNO
28
How many drinks per week on average?One drink is a 5 oz glass of wine, a 12oz bottle of beer, a 1.5oz shot of hard alcohol
29
I am...* This field is required.Please choose one.
Single
Married
Widowed
Domestic Partnership
Other
Divorced
30
Who is in your support system?* This field is required.Please describe your support system. Family, friends, other forms of support.
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Ok
31
Additional information you might want to share with our navigator......please let us know!
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32
Please review the CSS Policies + PracticesYou will e-sign on the next page
33
Please sign that you have read and agree to each of the CSS Policies & Practices.* This field is required.By signing my name below, I agree that I have read and agree to each of the CSS Policies and Practices.
Clear
34
Please review our Consent for Treatment form.You will e-sign on the next page
35
Please sign here to indicate that you have read and agree to our Consent for Treatment form.* This field is required.
Clear
36
View the Notice of Privacy Practices
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