PROSPECTIVE PATIENT FORM

Name

First NameMiddle InitialLast Name

Age:

Date of Birth:

Date

Today's Date:

Date

Phone Number:

Format: (000) 000-0000.

Email Address:

example@example.com

City, State, Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Who referred you to us?

What type of cancer do you have?

When were you first diagnosed?

What stage is the cancer?

What organs/tissues has it metastasized (spread) to?

What are the dates and results of your most recent scan (CT, MRI, PET) and/or tumor markers?

What treatments and/or surgeries have you had for cancer thus far and what were the results?

What side effects are you experiencing from your current treatment?

Treatment Expectation:

Please answer each question below to the best your knowledge:

Type an X in the appropriate box:

Rows	Yes	No	Unsure
Do you have any mental, physical, or financial condition(s) that prevents adherence to a recommended treatment plan?
Are you willing to incorporate conventional therapy when appropriate?
Do you have compromised kidney and/or liver function?
Do you have elevated iron levels?
Do you have elevated inflammatory markers?
Do you have severe anemia?
Do you have a low albumin level?
Do you have jaundice (yellow tint to the skin or eyes caused by elevated bilirubin)?
Do you have severe cachexia (muscle wasting)?
Do you have ascites (fluid in the abdomen), pleural effusion (fluid between the lungs and chest wall), and/or generalized swelling throughout the body?
Are you experiencing uncontrollable pain and/or nausea?

Email to: Info@HealthyAndStrong.com

Daniel Thomas, DO, MS | Sylvia Torres-Thomas, PhD, APRN, FNP-C
1741 Ocoee Apopka Rd. | Apopka, FL 32703 | Phone: (352) 729-0923 | Fax: (888) 481-6799