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Patient Worksheet
Date |
Treatment |
Place |
Ride |
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If you need to reschedule an appointment, please call _______________ as soon as possible.
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You can use this form to note any problems that you are having. Please bring this form as a reminder when you visit your doctor or nurse. Don't wait to report high fever, vomiting, persistent diarrhea (lasting more than 3 days), or any health emergency. |
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Date |
Symptoms or Questions |
In Case of an Emergency
Physician:
Telephone numbers:
Hospital:
Ambulance/emergency squad:
Current cancer chemotherapy
Other current medications
Special instructions
CALL DAY OR NIGHT:____________________
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Top - Colon Library Index - Camptosar Index
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