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2. disease
3. cancer

Monter Cancer Center
How to Prepare for Your First Appointment
It is my pleasure to welcome you to the Division of Medical Oncology/Division of Hematology of the
North Shore-LIJ Health System located at Monter Cancer Center. I look forward to meeting you at your
first appointment. The Monter Cancer Center is located at:
North Shore-LIJ Center for Advanced Medicine
Monter Cancer Center
450 Lakeville Road
Lake Success, NY 11042
Directions and map are located on an enclosed informational card
The goal of the entire staff at the Monter Cancer Center is to provide quality care individualized to meet
all your needs. I have enclosed information about some of the many services we provide. Please note
that since our practice encompasses a wide variety of hematologic and oncologic diseases, some of this
information may not be applicable to you. I have also included information on what to expect on your
first visit along with a medication flow sheet and registration forms which we recommend that you
complete and bring to your first visit.
I, along with the entire staff of the Monter Cancer Center, would like to thank you for the trust and
confidence you have placed in our practice by choosing us as your care provider. If you have any
questions, or if I can be of any assistance to you at any time, please contact me at (516) 734-8837.
Sincerely,
Barbara Thiem RN, BCN, OCN
New Patient Navigator
Monter Cancer Center
To optimize the results of your first appointment visit, it is very important that you bring several items
so that your physician has the information he/she needs to better understand your medical history and
any treatment interventions to date. Any questions you may have can be addressed by our Nurse
Navigator, Barbara Thiem, RN, who can be reached at (516) 734-8837.
What should I bring?
At the time of your first appointment, you should have completed and brought with you:
• registration form
• record release form
• consent for release of information
• medical history form
which are included in this New Patient Appointment Packet. Also remember to bring your referral if
required, insurance cards, a photo ID and a prepared list of questions you may have.
In addition, prior to your appointment we will need:
Tissue biopsy slides, if applicable (not needed if done at North Shore University or LIJ
Hospital)
o Bone marrow slides-if performed (not needed if done at North Shore University or LIJ
Hospital)
o Pathology reports
o Radiology reports
o Radiology studies (CT, MRI, PET etc. on Disc or film)
o Operative Reports
o Physician Notes
o Detailed Treatment Records
o Laboratory Results
o Ekg (If done within the last 60 days)
Please fax these records ASAP to (516) 734-8790 or (516) 734-8865.
o
Please have your radiology discs and pathology slides sent via overnight delivery before your
appointment. It is ideal to have them at least 2 days prior to your appointment date for your doctor to
provide you with a comprehensive evaluation and give you a complete recommendation. If this is not
possible, please bring pathology slides and radiology discs with you to your appointment.
It is also suggested that a family member or trusted friend accompany you on your initial visit so that an
additional person hears what the physician recommends.
When should I arrive?
Please arrive at least 20 minutes prior to your scheduled appointment time. Upon arrival at The Monter
Cancer Center you will be welcomed by our staff and guided to the reception desk where you will checkin and be registered. You will then be seated in the reception area until you are called to the laboratory
for bloodwork. It is standard practice for all hematology/oncology patients to have a CBC (complete
blood count) done as part of their evaluation. Upon completion of the bloodwork you will return to the
reception area until you are called to a consultation room to meet with your physician.
How long will I be there?
To ensure that you receive a complete evaluation, expect to spend approximately 2 hours at your initial
visit. Subsequent visit times will vary dependent upon treatment plans and any testing that may be
prescribed. Since there may some times be a wait to see your physician, there is a café available for
your use, in addition to vending machines containing snacks. Magazines are also available, as well as a
reception area offering a plasma television.
What will happen during my initial visit?
During this visit, once you have had your CBC done, you will meet with the nurse navigator who will
welcome you and assist with any questions you may have. You will then have your consultation with
your physician. At this time, the physician will review your records and current condition, conduct a
physical examination and have a discussion of your individual treatment needs. Sometimes this will
require additional testing or specialty referrals to be made to other members of the cancer care team.
At the end of your initial consultation, you will have the information you need, have all your questions
answered and have a plan for treatment and/or follow-up in place.
The Clinical Trials Program
At The Don Monti Division of Medical Oncology/
Division of Hematology at the Monter Cancer Center
We are committed to helping you through this challenging time. We are fortunate to be able to provide
the full range of state-of-the-art therapies through our Comprehensive Care Program. We are proud to
be part of a national cooperative organization to offer clinical trials to improve the care and provide
treatment of people who are diagnosed with cancer. This involvement ensures that the most up to date
and “cutting edge” investigational therapies are offered on Long Island to patients who are diagnosed
with cancer.
Below please find some information to help you better understand clinical trials and if it is the right
decision for you:
What is a clinical trial?
A clinical trial is a research study involving patients to assess a new treatment or to compare treatments
presently being used. Clinical trials may help to determine If one treatment is more useful for a certain
group of patients and are often foundation for new and better treatments. This information is meant to
assist you and your family in making a better decision about entering a trial.
How do I know if I am eligible for a clinical trial?
Studies will often enroll patients with a specific type of illness. If you meet the criteria for the clinical
trial, you may be eligible to participate in the study. Your physician will discuss this with you when
applicable.
What is informed consent?
This is the process of your physician explaining a clinical trial including possible risks, benefits and
alternative treatments. The consent form will explain what is required of you, such as taking medication
on a schedule, following up with the study physician or your private physician, or taking certain blood
tests or other procedures. You will then decide if you would like to participate in the study. If you agree
to participate in the study, you will be asked to sign a consent form stating that the information has
been given to you (informed consent). Even if you sign the consent form, you may decide to withdraw at
any time during the trial.
What are the advantages and disadvantages of being in a clinical trial?
Patients in a clinical trial are often among the first to receive new treatments before they are widely
available. Although there is the possibility that a new treatment will not reach its goals, the researchers
involved in the study have reason to believe that it will enhance the present treatments or provide a
viable alternative. If you are enrolled in the clinical trial, study medications may be supplied to you at no
additional cost.
For additional information on hematology/oncology clinical trials, please call Lori Megherian, Senior
Administrative Director, Clinical Research at (516) 734-8248 or visit clinicaltrials.gov.
Monter Cancer Center
Chemotherapy Orientation Course
This is a program for patients beginning chemotherapy and for those currently receiving treatment who
want additional information. When you attend this course, we encourage you to bring one family
member or friend with you. Courses begin on time and last one hour, so please arrive 10 minutes before
the session begins.
Course Location:
Monter Cancer Center
450 Lakeville Road
Lake Success, NY 11042
Registration is required. To register please call the Monter treatment room secretary at (516) 734-8888,
Monday – Friday, 9am – 5pm.
Monter Cancer Center
Pathology Slide Submittal
It is essential that all written reports be sent to the Monter Cancer Center prior to your consultation. If
your pathology (biopsy) slides were not read or reviewed at North Shore University Hospital or LIJ
Hospital pathology department, we will need to have them reviewed prior to your consultation. Please
contact your referring physician’s office to request your pathology slides be sent to the Monter Cancer
Center.
You may need to pick up the pathology slides in person or have the pathology slides sent via Fed-Ex to:
Attention: New Patient Department
Monter Cancer Center, Building A
450 Lakeville Road
Lake Success, New York 11042
Please note that if your pathology slides are not obtained prior to your consultation, it may delay your
physicians from developing a treatment plan and any treatment you may need.
North Shore-LIJ Cancer Institute
Patient History Form
Your answers will help us plan and provide your care. Leave blank any parts you are unsure of or do not wish to answer. We will review
the form with you. Any information we gather will be kept confidential. PRINT AND USE INK.
Patient Name:__________________________ PERSON COMPLETING THIS FORM:
PATIENT
OTHER(Name/Relation to Patient) _________________________
D.O.B.: ____________
Today’s Date:_______________
PRIMARY LANGUAGE:
Gender:
Male
Female
CURRENT MEDICAL HISTORY:
PREFERRED LANGUAGE:
English
Spanish
Other ________________
What is your main reason for your visit? (Chief complaint)____________________________________________________________________________
Provide history of your current problem: (When it started; symptoms; any prior treatments) ________________________________________________ _
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
Are you ALLERGIC to anything?
No
Yes - If yes list what it is and type of reaction ______________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
PAST MEDICAL HISTORY: please check ALL previous illnesses or conditions below.
Heart problems
Lung problems
Diabetes
Blood Pressure problems
Liver problems
Thyroid problems
Circulation problems
Kidney/urine problems
Frequent infections
Stroke or seizure
Bleeding problems
HIV/AIDS
Digestive problems
Psychological/Psychiatric problems
Other
Please provide any more information below for the conditions/ illnesses mentioned or would like us to know about:__________________
___________________________________________________________________________________________________________________________________________
Do you have any problems with:
Hearing
Vision
Please complete the TABLE below for any PRIOR cancer, radiation treatment or chemotherapy that you have had.
No
Prior Cancers (before current illness):
Prior Radiation Treatment
(not dental x-rays or for broken bones):
Prior Chemotherapy
Yes
Year
Type of Cancer
North Shore-LIJ Cancer Institute
Past Hospitalization (include reason and date): ______________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Past Surgeries (include type of surgery and date): ____________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
CURRENT MEDICATIONS (include prescription, over the counter and herbals):
NAME OF MEDICINE
DOSE
HOW
OFTEN
TAKEN
REASON FOR TAKING
REVIEW OF SYTEMS: Check the following problems that you are having NOW:
GENERAL
SKIN:
NONE
OTHER
NONE
OTHER
Fever-chills
Open sore
Sweats- night or day
Change in moles
Change in sleep habits
Abnormal color
Fatigue
Rashes
Weight gain
Weight loss
Pain-location____________________
GASTROINTESTINAL/NUTRITION:
NONE
OTHER
Yellow skin or eyes
Nausea/vomiting
Difficulty swallowing
Cramping/stomach pain
Change in appetite/diet
Indigestion/Reflux
Diarrhea
Constipation
Black stools
Blood in stools
GENITOURINARY:
NONE
burning
Frequency
Blood in urine
dribbling
unable to control bladder
MUSCULOSKELETAL:
NONE
Joint swelling
Joint/back pain
stiffness
trauma
falls
OTHER
OTHER
DATE MEDICATION WAS STARTED
(APPROXIMATE)
NEUROLOGICAL:
NONE
OTHER
Numbness/tingling
Dizziness/fainting
Blurred vision
Headache
Hearing difficulty/Ringing
Seizures
Speech changes
Unbalanced walking
RESPIRATORY:
NONE
Wheezing
Cough
Short of breath
Bloody phlegm/sputum
ENDOCRINE:
NONE
Cold intolerance
Hot flashes
OTHER
OTHER
North Shore-LIJ Cancer Institute
HEAD & NECK:
NONE
Nose bleeds
Hoarseness
Sores in mouth or throat
Sore throat
HEMATOLOGY/LYMPH:
NONE
OTHER
Abnormal bleeding
Prior transfusion
Easy bruising
Swelling in groin/armpit/neck
OTHER
BREAST:
NONE
OTHER
Changes
Lumps
Nipple discharge
Date of last
mammogram:_______________
PSYCHOLOGICAL:
NONE
Worried/anxious
Sad/depressed
CARDIOVASCULAR:
NONE
Leg pain/swelling
Chest pain
Fast heart beat
OTHER
OTHER
FAMILY HISTORY: List any cancers or blood disorders(i.e. bleedings, clots, anemia) in your family
Relative Type
Year born
Still living
Yes
No
Age
Died?
Ever smoked
Yes
No
SOCIAL HISTORY:
Do you drink alcoholic beverages regularly (at least 5 drinks/week)
Kind/location of cancer
Yes, currently
Yes, but quit
Never/rarely
Have you ever smoked/chewed tobacco during your lifetime?
Yes, currently. Packs/day ______
Yes but quit smoking; year_______
If you used tobacco in the last 12 months, was it Cigarettes / Cigars / Pipe / Chewing Tobacco (circle all that apply)
Have you ever used any recreational (street) drugs?
Yes, currently
Yes, in past
Never2
NUTRITION
I’ve had unintentional weight loss or weight gain of greater than 10 pounds
MARITAL HISTORY
Status:
Single, never married
Married
With whom do you live? (check all that apply)
Spouse
Domestic Partner
Children
Separated
Divorced
Parent(s)/Parent(s)-In -Law
Widowed
Live Alone
Age
Diagnosed
Others
HEALTH SCREENING MAINTENANCE
Have you ever had any of the following?
Colonoscopy
Date:________________
Prostate exam
Date:________________
Pap Smear
Date:________________
Mammogram
Date:________________
FOR WOMEN ONLY
Have you gone through Menopause
No
Yes
Date of last menstrual period:__________________________
Age of first menstrual period___________ Number of pregnancies___________________ Age of first Pregnancy________________
Ever been treated with Hormone replacement therapy No
Yes if so, when:_____________________
No
North Shore-LIJ Cancer Institute
PAIN ASSESSMENT
1.
Have you experienced pain in the last month?
No (Stop Here)
Yes (Answer remaining questions to describe your pain)
2. Are you being treated for this pain?
No
Yes, by whom? ____________________________________________________________________
3. List the locations of your pain.______________________________________________________________________
4. Circle the number that best describes the amount of pain you are having (How strong is the pain?)
0
1
2
3
4
5
6
7
8
9
10
No pain
Worst pain imaginable
5. How much does your pain interfere with your daily activities?
0
1
2
3
4
5
6
7
8
9
10
Not at All
Completely
6. What makes the pain better? ____________________________________________________________________________________________
7. What makes the pain worse? ____________________________________________________________________________________________
8. Are you taking medication for pain?
No
Yes
9. If yes, list all medications you are taking for pain. Include prescription medications, over the counter medications, and herbal remedies _______
10. Are you using other treatment for pain? (heat, cold, physical therapy, acupuncture, hypnosis)
No
Yes
11. If yes, list all of these treatments _________________________________________________________________________________________
Would you like to see any of the following resources:
Social Worker
Nutritionist
Financial Advisor
Spiritual Care
Patient Signature ____________________________________________________ Date:______________________________________
I HAVE REVIEWED THIS SELF ASSESSMENT WITH THE PATIENT
Physician Signature:_________________________________________________ Date:______________________________________