Recent Posts
Archives
Contact The Wilmslow Hospital
Home / Contact The Wilmslow Hospital
Contact details for appointments

Please contact mrs Deniz Valiantis
(private secretary) at:
The Christie Clinic and Wilmslow Hospital,clone rolex datejust rolex calibre 2836 2813 m126201 0034 mens silver fluted dial
Manchester
M20 4BX.
Tel: 0161 918 7984
Fax: 0161 446 8027

E-mails: d.valiantis@nhs.net

or

Rochelle.Whittaker@hcahealthcare.co.uk

Address

52-54, Alderley Road
Wilmslow , Cheshire
SK9 1NY

http://www.52alderleyroad.co.uk

contact-Christie
Candidate Form






    1. Your Contact Information

    First Name
    Last Name
    Address
    City
    Zip
    Phone
    Additional Phone
    E-mail

    2. Getting to Know You!

    Your Height
    Your Weight
    Breast Size
    Your Age
    Gender MaleFemale
    Month / Day / Year

    3. Primary Insurance

    Person Responsible for Account
    Insurance Company
    Insurance Company Phone
    Address
    City
    Zip
    Subscriber Number
    Group Number
    Primary Care Doctor
    Oncologist / General Surgeon

    4. History of Present Breast Illness

    When Did the Breast Condition First Occur?*

    How was it Diagnosed?
    What side it the Tumor on?
    What Type of Tumor (if known)?
    What was the Size of the Tumor?
    Number of Lymph Nodes Removed?
    Number of Nodes Positive?
    Date of Mastectomy
    Mastectomy Surgeon
    Date of Lumpectomy
    Lumpectomy Surgeon
    Date of Sentinel Lymph Node Procedure
    Describe any other breast surgery you have had so far (including reconstruction if any)
    Have You Had Chemotherapy? YesNo
    From/To/Medication
    Have You Had Radiation Therapy? YesNo
    From/To/Medication

    5. A Little About Your Personal History

    What Age Your Period Began
    Age at Your First Pregnancy
    Number of Pregnancies / Number of Live Births
    Date of Last Mammogram
    Breast Lump or Discharge? YesNo
    Do You Breast Feed? YesNo
    Do You Do Regular Breast Self-Examinations? YesNo
    Personal Use of Birth Control Pills? YesNo
    Treatment for Infertility? YesNo
    Do You Still Have Your Ovaries? YesNo
    Have You Taken Estrogen Hormone Replacement Medications? YesNo
    Have You Had Generic Testing for the BRCA Gene Mutation? YesNo
    Results*

    6. Lymphedema History (Please Fill in All Applicable Fields)

    Side RightLeftBothN/A
    Extremity RightLeftBothN/A
    Have You Had Lymphatic Drainage by a Physical Therapist? YesNo
    Do You Wear a Compression Garment? YesNo
    If Yes, When? DaytimeNighttimeBothN/A
    If Yes, What Pressure? 20-3030-4040-50Not sure
    Do You Use a Pneumatic Pump? YesNo
    If Yes, How Often?
    Have You Had Any Infections Requiring Antibiotics? YesNo
    Have You Had Any Infections Requiring Hospitalization? YesNo
    How Many Infections Do You Have a Year? 0-23-56-1011-15+16
    Have You Had Any Additional Treatment for Your Lymphedema?

    7. Past Medical History

    Have You Had Any of the Following?Heart DiseaseArthritisRheumatic FeverAnemiaTuberculosisDiabetesBlood ClotsGlaucomaAsthmaAIDS or HIVStrokeHepatitisStomach UlcerKidney DiseaseThroid DiseaseBleeding TendencyMitral Valve ProlapseHigh Blood Pressure
    Drug Allergies*

    8. Past Medical History

    Please List Any Major Illnesses and Dates

    Date (MM/DD/YEAR)
    Illness
    Date (MM/DD/YEAR)
    Illness
    Date (MM/DD/YEAR)
    Illness

    Please list all your past surgeries and dates

    Date (MM/DD/YEAR)
    Procedure
    Date (MM/DD/YEAR)
    Procedure
    Date (MM/DD/YEAR)
    Procedure

    9. Current Medications

    Please include asprins, ibuprofen, birth control pills, etc. and dosage.

    Medication
    Dosage
    Medication
    Dosage
    Medication
    Dosage
    Medication
    Dosage
    Medication
    Dosage

    10. Bleeding Disorders

    Have you or any of your relatives had problems with blood clots or bleeding?

    11. Family History

    Please list any blood relatives with cancer.

    Type of Cancer
    Relationship
    Type of Cancer
    Relationship
    Type of Cancer
    Relationship
    Type of Cancer
    Relationship
    Type of Cancer
    Relationship

    12. Social History

    Do you smoke? YesNo
    Type / Amount Per Day
    Do you drink? YesNo
    Type / Amount Per Day
    Occupation
    Marital Status *
    Spouse Occupation
    Number of Children

    13. Physical Activity Level

    Does your work require any physical activity? YesNo
    Often Do You Exercise?
    Do you have back pain? YesNo
    What Types of Activity Do You Enjoy?

    14. Review of Symptoms

    Have You Had Any of the Following?Weight ChangeDry EyesChronic CoughChest PainRapid Heat BeatAbdominal PainSwollen Feet/AnklesSkin RashChronic DiarrheaJaundiceDepressionHeartburn RefluxSeizuresJoint or Muscle PainUrinary SymptonsEasy BleedingEasy BruisingSwollen Lymph Nodes
    Drug Allergies*