Name/Birthdate ______________________________________________________

Relevant Medical History

Surgeries and Medical Events by decades/years

1940

1950

1960

1970

1980

1990

2000

2010


The above should include childhood illnesses, accidents, organ problems, etc.

Myeloma Diagnosis and treatment by date

Date of diagnosis

Treatment plan- Name of drugs, length of treatment, date of relapse/ or changes.

Kind of stem cell transplant if received? (Autologous or Allogeneic) and associated chemo/drugs, name of hospital. 

Maintenance drugs?

Blood or platelet transfusions? 

Kind of remission (Complete response, partial response or no response)

Date of relapse

Bisphosphonates schedule if any

Myeloma related medical events
Shingles /Herpes Zoster? 

Problems with heart, lungs, kidneys, or other major body organs

Port infections?

Bone fractures or lesions

Other cancers?

Other events?


All current medications with dosage level and schedules









Allergies

Relevant Family History
Paternal 

Maternal

Siblings

Contact information for all relevant doctors Names, phone numbers, hospitals, etc. 
You may need this information if you visit an emergency room in your hometown or elsewhere. An ER doctor may prefer consulting with your physician before treating you. Moreover, you will want all records of your ER visit sent to your oncologist. Include name, clinic address and phone numbers or email addresses.