CANCER CONSULTATION FORM

Personal Information

Patient’s Name

:  

Address

:  

Phone

:  

E-mail

:  

Male/Female

:  

Date of birth/Age

:  

Normal weight

:  

Present weight

:  

Occupation ( If working in hazardous environment please specify)

:  

Part – 1 Cancer Diagnosis

Main cancer type

:  

Location in body organ

:  

Date diagnosed

:  

Type/grade

:  

Stage

:  

Metastasis or recurrence location

:  

Hospital

:  

Details (If any)

:  

Advised Treatment By Doctors

Part – 2 Surgeries

Surgery

: Yes   No

Hospital

:  

Surgery details

:  

Part – 3 Chemotherapy

Chemotherapy

: Yes   No

Type of Chemotherapy

:  

Date started

:  

Date completed

:  

Hospital

:  

No. of treatments

:  

Additional information (If any)

:  

Part – 4 Radiation

Radiation

: Yes   No

Radiation Dose (RADS) or Centagrays

(CYG)

:  

Hospital

:  

Date initiated

:  

Date completed

:  

Part – 5 Other Complaints, Treatments, Therapies, side effects if any of treatments etc,

( If Any )

Part – 6 Present Condition

Appetite

:  

Constipation/Diarrhea

:  

Jaundice

:  

Pain

:  

Bleeding/Anemia

:  

Other (please specify)

:  

Part – 7 Personal Lifestyle

Habits/Routine

:  

Food habits

:  

Addictions if any

Occupation/Present activity

:  

Hobbies

:  

If interested in pranayam, yoga, meditation please state

: