Patient Assessment

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.

Full name

Date of birth

Occupation

Phone number

Email address

DESCRIBE BRIEFLY YOUR PRESENT SYMPTOMS

Are you allergic to anything?

PAST MEDICAL HISTORY : High Cholesterol, Asthma, Heart Disease, High Blood Pressure (hypertension),High Cholesterol, Renal (kidney) Disease, etc.

Have you ever had any prior cancers (before your current illness of cancer)? If YES, please list prior cancer, the date you were diagnosed, and the date of treatment completion:

Have you had prior chemotherapy? Please provide details

Have you had prior radiation treatment? Please provide details

MEDICATION : Please list any medications and supplements that you take on a daily or frequent basis. Include prescriptions andover-the-counter medications, vitamins, minerals, herbs, and any other supplements.

Have you had any past surgeries? If YES, please list the surgery you had and the date:

Do you have any family history of chronic illnesses (for example, diabetes, heart disease or cancer)?

BIOPSY RESULTS

PET/CT SCAN RESULTS

ULTRASOUND RESULTS

CT (computerized tomography)

BLOOD RESULTS (For the last 3 months)

Medical Summary Report

Do you have a pacemaker or internal defibrillator?

MENTAL HEALTH PROBLEMS :

Do you drink alcohol? (include beer & wine)

How many cigarettes a day do you smoke? cigarettes/day OR packs/day

TREATMENTS YOU HAVE TAKEN IN THE PAST

Do you exercise regularly?

What kind of exercise and How often ?

How many hours, on average, do you sleep at night (or during the day, if working night shift)?

What is your current height and weight?

What did your weigh 1 month ago, 6 months ago and 1 year ago?

How would you describe your diet? : ( Regular, Low Cholesterol, Diabetic, Vegetarian, Low Salt ,Low Fat)

Compared to normal, how would you rate your food intake during the past month? ( Unchanged ,More than usual, Less than usual)

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?

Do you have any open wound , skin infection or scars ?

Do you need a translator ?

First date of last menstruation period ( for Women )

Age of First Menstruation ( for Women )

WHAT IS YOUR MAIN CONCERN REGARDING YOUR ILLNESS AND TREATMENT?

WHAT QUESTIONS MAY WE ANSWER FOR YOU?