Patient Form

Prospective new patients for Integrative Cancer Therapy Centers should complete the following information. A physician will review this and arrange for a private consultation. Please complete all of the information found on this form. This information will only be used to assist us with providing you the specific program components designed for your specific needs.

 
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* Required information.
Your Name *
Telephone *
Email *
City *
State
Country *
Occupation
Age
Sex
Male
Female
Marital Status
Single
Married
Divorced
Widowed
What is your diagnosis?
When was your diagnosis made?
List your symptoms and complaints
Treatments received and their dates (e.g. chemotherapy, radiation, surgery, other?
Do you suffer from pain?
Yes
No
List the names and amounts of the pain medications you take, if any:
Do your bowels move regularly?
Yes
No
Has there been any recent changes in your bowel movements or stools?
Yes
No
Do You Exercise Regularly?
Yes
No
What type of exercise and how often?
Do you sleep well?
Yes
No
Do you sleep an average of 8 hours?
Yes
No
Is your diet well balanced?
Yes
No
Has there been any recent changes in your appetite or eating habits?
Yes
Do you drink alcoholic beverages?
Never
Rarely
Moderate
Daily
Cigarettes - how many packs per day?
Pipe?
Yes
No
Chewing?
Yes
No
Cigars?
Yes
No
Snuff?
Yes
No
Recreational drugs?
Never
Occasionally
Frequently
Daily
Laxatives?
Never
Occasionally
Frequently
Daily
Vitamins?
Never
Occasionally
Frequently
Daily
Sedatives (e.g. sleeping pills)?
Never
Occasionally
Frequently
Daily
Tranquilizers?
Never
Occasionally
Frequently
Daily
Aspirin?
Never
Occasionally
Frequently
Daily
Steroids?
Never
Occasionally
Frequently
Daily
Thyroid medications?
Never
Occasionally
Frequently
Daily
Appetite suppressants?
Never
Occasionally
Frequently
Daily
Have you ever been treated for drug habits?
Yes
No
Do you take insulin or pills for diabetes?
Yes
No
Hormone replacement therapy?
Yes
No
How many hours a day do you work indoors?
How many hours a day do you work outdoors?
Age of onset?
Is your menstrual cycle regular?
Yes
No
Usual duration in days?
Yes
No
How is your cycle?
Heavy
Moderate
Light
Pain or cramps?
Yes
No
Date of last period?
How many children born alive?
How many children born premature?
How many cesarean sections?
How many miscarriages?
Did you have any complications with any pregnacy?
Yes
No

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