First name
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Last name
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Birth date
Age
Marital status
Emergency contact person
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Country
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Phone number
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Phone number
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Email
Skype ID
WhatsApp
Line ID
Past health history:
Do you any allergies or are you sensitive to any drugs or substances?
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What are your medical and surgical histories? (Including hospitalization, accidents and surgery)
Cancer: please specify (organ)
Stage:
Metastasis to (organ):
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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?
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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?
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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
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Medical report (Attached)
BIOPSY
PET/CT
ULTRASOUND
CT scan (computerized tomography)
BLOOD RESULTS (For the last 3 months)
other
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Current Medicine and supplement
Do you have any trouble taking medicines /supplements?
How often do you have the trouble?
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Weight/kg
Height/cm
BMI
Have you had any recent changes in your weight that you are concerned about? If yes, please explain
Weight loss or gain? (amount)
Food intake / times a day
Fluid intake / liters of water per day
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?
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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?
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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)
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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?
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Respiratory
Have you ever had any difficulty breathing? (This includes asthma, emphysema, chronic cough, pneumonia, Tuberculosis, or any other lung disorder)
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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?
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Value-Belief Pattern
What is your religion?
Do you pray, if so how long?
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?
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Age at first menstrual period
First day of last normal menstrual period
Length of entire cycle / days
Last Pap Smear
If yes, when?
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If you are human, leave this field blank.
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