Personal Information Form

Family name

First name

Date of Birth

Sex

Address (street/ house number/ area/ town/ country) Postal code/ country

Phone (incl.area code)

Email

Cancer History

What type of cancer?

Primary

Metastases

When were you diagnosed with cancer?

Did you have surgery? What kind?

What type of therapy have you undergone?

Please specify:

Are you currently in treatment?

Are you currently taking any medication?

What medications?:

Are you currently taking any supplements?

What supplements?:

Do you have any other medical conditions?

Please specify:

Do you follow a specific diet? (gluten free, dairy free, vegetarian, pescatarian, vegan, keto, etc)

In what areas do you feel you need support?

Anything else you would like to share?

How did you first come across The Cancer Coach?

Please specify:

If you would like to provide us with the following reports, please upload the documents by simply clicking 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

ADDITIONAL REPORTS

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 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.