Date of Birth
Address (street/ house number/ area/ town/ country) Postal code/ country
Phone (incl.area code)
Attending physician (address, phone)
What type of cancer do you have? (primary tumour/ metastases)
When was the tumor confirmed?
How did you first come across The Cancer Coach?
---Internet researchOwn researchDoctorPatientsMediaOther source
Is there anyone in your family, who has had a tumor? State how the person is related to you/ type of tumor which was diagnosed
Was your tumor removed?
First surgery date
Following surgery dates
What type of therapy have you undergone? include medicines and date of medicines taken, whenever possible
Are you currently taking any medicine, as part of a therapie? (if so, medicines and dates)
Were any operations necessary after this course of therapy? (dates)
We would like to draw your attention that we require your medical reports, diagnosises and any other relrevant information. With this information we can try to help you further.
Please complete in block capitals
Authorized person's name (if appropiate)
Patient's date of birth
Please tick the option (only one) which best describes the patient's current health state
Normal, no complaints, no evidence of diseaseMinor signs or symptoms of disease but able to carry on normal activitiesSome signs or symptoms of disease, normal activities with effort, tires more quicklyUnable to carry on normal activity or do active work but cares for herself/himselfRequires occasional assistance but is still able to care for most of his/her needs. Up and about more than 50% of waking hours.Requires considerable assistance and frequent medical care but still able to participates in all quite play and activitiesDisabled, requires special care and assistance, mostly in bed but still participates in some quiet activitiesSeverely disabled, hospitalization indicated, needs assistance even for quiet activitiesVery sick, hospitalization indicated, often sleeping, play entirely limited to very passive onesVery sick, illness proceeds rapidly, cannot carry on any care for herself/himself, no activity
Name of signing person
IF THE CANCER HAS METASTASIZEDTo what areas has it spread?
LIST YOUR KNOWN ALLERGIES
WHAT MAJOR SURGERIES DID YOU HAVE?
HOW WOULD YOU DESCRIBE YOUR MOBILITY LEVEL? (Please check if applicable)
I'm not dependent on another person and can perform everyday tasks on my ownI'm able to travel on my own but prefer to bring a caretakerI need assistance when climbing stairs, getting in or out of the bed or a carI am dependent on a caretaker during the dayI am dependent on a caretaker 24h a dayI need wheelchair assistanceI have to have oxygen supply on standbyI'm on constant oxygen supply
LIST ANY ADDITIONAL PREVIOUS AND CURRENT MEDICAL CONDITIONS
What kind of kidney disease and since when?
What type, dose and duration
Procedure date and additional information
Time of implantation and model
PLEASE PROVIDE A BRIEF HEALTH HISTORY
Please provide us with the following reports if you have them available. To upload the documents simply click the upload button and select the file to upload from your browser. (Each file size should not over 3MB and total file sizes should not over 15MB)
YOUR ONCOLOGIST REPORT
MRI/CT/PET SCAN REPORT
LATEST LAB WORK/BIOPSY REPORT/HISTOLOGY
I confirm that the information provided in this questionnaire is an honest and realistic description of my/the patient's current health state. I understand that if my/the patient's health state on arrival differs significantly from the description given in this questionnaire, The Cancer Coach has the right to decline treatment and this may result in already paid costs not being refunded to me.
Release and management of medical information: I understand that my medical information and records are kept confidential by The Cancer Coach.
I agree and consent that The Cancer Coach may disclose all or any part of my medical records to a referring physician, hospital, clinic and/or medical center for the purpose of discharging their duties.
I agree to release and hold harmless The Cancer Coach and its agent, representatives, employees from any and all liability associated with the disclosure of confidential patient information as authorized in this consent agreement and I do agree that The Cancer Coach is not responsible for the use or non-authorized disclosures of information by other to whom I have consented disclosures of my confidential information.
I acknowledge that my medical information, treatment and all its history in kept in medical and electronic medical record. If I do not receive services or treatment from The Cancer Coach for 5 consecutive year, my medical records and other treatment records (including imaging records) may be deleted and/or destroy.
I understand that this consent agreement will be valid and remain in effect as long as I am engaged with The Cancer Coach unless revoked by me in a written notice to the Authorized officer of The Cancer Coach
I certify that I have read and understand this consent agreement and accept all of its contents.
I have read and accept the Release and management of medical information
Please leave this field empty.