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

Past health history


Tobacco/ alcohol USE

PRESENT HEALTH

Perception and Health Management Pattern

Medical report (Attached)


Current Medicine and supplement

Name/Description, Dosage/Quantity, Frequency, REASON

Nutritional Assessment

(e.g., food preferences or restrictions, special diet, appetite); actual weight; weight loss or gain

ELIMINATION PATTERN

SLEEP-REST PATTERN

Describes patterns of sleep, rest, and relaxation

ACTIVITY-EXERCISE PATTERN

Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living

Respiratory

PAIN

Value-Belief Pattern

FOR WOMEN

Tell me about your menstrual history (onset, length, amount of flow, cramps, bloating, PMS, age of first period, age of menopause).

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