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.

GENERAL INFORMATION

First name

Last name

Birth date

Age

Gender

Marital status

Emergency contact person

Phone number

Email address

Skype ID

Line ID

Do you any allergies or are you sensitive to any drugs or substances?

Past health history

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

PET/CT

ULTRASOUND

CT scan (computerized tomography)

BLOOD RESULTS (For the last 3 months)

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

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

Height/cm

Weight/kg

BMI

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

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

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?

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

If yes, were your ovaries removed?

Yes

Last Pap Smear

History of abnormal pap smear?

Yes

If yes, when?

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AKESIS LIFE : Integrative Oncology
21 Fl., 253 Asoke Building, Sukhumvit 21 Road, Klongtoey-Nua, Wattana, Bangkok 10110

Patient Assessment

GENERAL INFORMATION

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

Send Inquiry

Call Us

E-mail

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