Patient Assessment Patient Assessment EN THIS IS A CONFIDENTIAL QUESTIONNAIRE TO HELP US DETERMINE THE BEST TREATMENT PLAN FOR YOU. PLEASE FILL IT OUT AS COMPLETELY AS POSSIBLE. THANK YOU. First name * Last name * Birth date Age 50 Gender Male Female Marital status Current address & living country Current address & living country Current address & living country Current address & living country City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Emergency contact person * Country * Phone number * Phone number * Email Skype ID WhatsApp Line ID Past health history: Do you any allergies or are you sensitive to any drugs or substances? * What are your medical and surgical histories? (Including hospitalization, accidents and surgery) Cancer: please specify (organ) Stage: Metastasis to (organ): Tobacco/ alcohol USE: Do you drink alcohol? If yes, how much and how often? How long ago & duration: Do you smoke? If yes, how many cigarettes per day? How long ago & duration: Are you an ex-smoker? If yes, when did you quit? Live with a smoker? Yes No PRESENT HEALTH Please describe your current state of health (location of the symptom, severity, duration and signs/symptoms) Family History: how is the family’s health? Perception and Health Management Pattern Are you currently receiving treatment for any of these conditions? If yes, please describe what kind of treatments, where and when? Have you ever received radiation therapy? first date last date location: Have you ever received chemotherapy? Please specify name of chemo drugs and how many cycles of chemotherapy Please specify: first date last date Medical report (Attached) BIOPSY Drop a file here or click to upload เลือกไฟล์ Maximum file size: 5MB PET/CT Drop a file here or click to upload เลือกไฟล์ Maximum file size: 5MB ULTRASOUND Drop a file here or click to upload เลือกไฟล์ Maximum file size: 5MB CT scan (computerized tomography) Drop a file here or click to upload เลือกไฟล์ Maximum file size: 5MB BLOOD RESULTS (For the last 3 months) Drop a file here or click to upload เลือกไฟล์ Maximum file size: 5MB other Drop a file here or click to upload เลือกไฟล์ Maximum file size: 5MB Current Medicine and supplement Please list all of the following taken currently: all medications, hormone replacement therapies ,vitamins, minerals, herbals, supplements, protein powders Name/Description, Dosage/Quantity, Frequency, REASON Drop a file here or click to upload เลือกไฟล์ Maximum file size: 5MB Do you have any trouble taking medicines /supplements? How often do you have the trouble? Nutritional Assessment (e.g., food preferences or restrictions, special diet, appetite); actual weight; weight loss or gain Weight/kg 75 Height/cm 150 BMI Have you had any recent changes in your weight that you are concerned about? If yes, please explain Weight loss or gain? (amount) Appetite Good (eat 3+ meals/day) Fair (1‐2 meals/day) Poor (less than 1 meal/day) Food intake / times a day Fluid intake / liters of water per day Do you find yourself eating processed foods often? (This includes red and packaged meats, frozen meals, and white bread but excludes homogenized milk and frozen veggies) Always Often Sometimes Rarely Never What is your diet menu? Please describe your daily meal(s) Any food restriction regarding disease point of view? Any food restriction regarding religious point of view? What kind of food do you like? What kind of food do you dislike? Do you have any physical conditions that restrict food intake, such as mouth ulcers, difficulty swallowing? Yes No ELIMINATION PATTERN How often do you have a bowel movement? (Describe) Frequency? Character? Discomfort? Problem in control? If you take laxatives, what type/brand and how often? Urinary elimination pattern? (Describe.) Frequency? Problem in control? SLEEP-REST PATTERN Describes patterns of sleep, rest, and relaxation How many hours of sleep do you average a night? Sleep onset problems? Dreams (nightmares)? Early awakening? What do you feel after waking? (Fresh, headache, drowsy) Are you using any medication for sleeping? Yes No ACTIVITY-EXERCISE PATTERN Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living Activities of Daily Living (ADL) In the past 7 days, did you need help from others to perform everyday activities such as eating, getting dressed, grooming, bathing, walking, or using the toilet? Instrumental Activities of Daily Living (ADL) In the past 7 days, did you need help from others to take care of things such as laundry and housekeeping, banking, shopping, using the telephone, food preparation, transportation, or taking your own medications? Do you have any illnesses that affect to your movement such as tiredness or pain when moving, pain? please specify details: How many times per week do you do stretching exercises to improve the flexibility of your back, neck, shoulders, and legs? On those days that you engage in moderate to strenuous exercise, how many minutes on average do you exercise and what type of exercise? Respiratory Have you ever had any difficulty breathing? (This includes asthma, emphysema, chronic cough, pneumonia, Tuberculosis, or any other lung disorder) Need oxygen support Yes No PAIN Do you suffer from chronic pain? (2 months or more of continuous pain) Describe the symptom(s). Where in the body does the symptom occur? Is there radiation or extension of the symptom(s) to another area of the body? On a scale of 0-10, (10 being the worst) how bad is the symptom(s)? What makes the symptom(s) better or worse? Does it occur in association with something else (i.e., eating, exertion, movement)? Does anything make it better? Value-Belief Pattern What is your religion? Do you pray, if so how long? Please circle the number (0-10) that describes the best of your distress level over the weeks. 0 (No distress) 1 2 3 4 5 6 7 8 9 10 (Extreme distress) How often is stress a problem for you in handling? such things as: your health, your finances, your family or social relationships or your work Never or rarely Sometimes Often Always How often do you get the social and emotional support you need? Always Often Sometimes Rarely Never If you have stress, then what is your coping mechanism towards stress? What makes you feel relaxed? What makes you worry? Do you believe that a regular holistic health routine will improve your lifestyle? FOR WOMEN Tell me about your menstrual history (onset, length, amount of flow, cramps, bloating, PMS, age of first period, age of menopause). Age at first menstrual period First day of last normal menstrual period Length of entire cycle / days Menopause at age Yes No If yes, were your ovaries removed? Yes No Last Pap Smear History of abnormal pap smear? Yes No If yes, when? Submit If you are human, leave this field blank.
