Send Inquiry - Akesis Life - Integrative Oncology

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

City

State/Province

Zip/Postal

Country

Emergency contact person

Country

Phone number

Email

Skype ID

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

Maximum file size: 5MB

PET/CT

Maximum file size: 5MB

ULTRASOUND

Maximum file size: 5MB

CT scan (computerized tomography)

Maximum file size: 5MB

BLOOD RESULTS (For the last 3 months)

Maximum file size: 5MB

other

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

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)

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?

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?

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?

Patient Assessment

Past health history:

Tobacco/ alcohol USE:

PRESENT HEALTH

Perception and Health Management Pattern

Medical report (Attached)

Current Medicine and supplement

Nutritional Assessment

ELIMINATION PATTERN

SLEEP-REST PATTERN

ACTIVITY-EXERCISE PATTERN

Respiratory

PAIN

Value-Belief Pattern

FOR WOMEN

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02-012-1948

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