SIM NATURALS LIMITED Comprehensive Integrative Oncology Assessment Form

SIM NATURALS LIMITED Comprehensive Integrative Oncology Assessment Form

Medical & Non-Surgical Aesthetic Clinic International Integrative Cancer Care Program.
Thank you for choosing Sim Naturals Limited. This assessment helps us understand your health, medical history, nutrition, and treatment journey so we can prepare a personalized integrative care plan before your consultation. Estimated completion time: 20–30 minutes.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender

Other
Country of Residence
Contact Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cancer Diagnosis
Type of Cancer
Date of Initial Diagnosis

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cancer Stage (if known)
Metastasis Present?
What other Parts of the Body has the Cancer Spread to
Clinical Risk Screening
Do you have any allergies?
Please list your allergies.
Has your oncologist advised you to avoid any foods or supplements?
Currently receiving chemotherapy?
Currently receiving radiotherapy?
Currently receiving immunotherapy?
Surgery within the last 30 days?
Unintentional weight loss?
Difficulty swallowing?
Severe nausea?
Severe vomiting?
Feeding tube?
Hospital admission within the last 30 days?
Pain score (0–10)
Appetite score (0–10)
Current Medical Treatment
Please provide treatment details
Medical History
Current Medications
Upload your medical reports

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Upload any additional medical reports

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Current Medical Treatment
Are you currently receiving any cancer treatment?
Medical History
Please list any major past illnesses, surgeries, or hospitalizations.
Do you have any other significant health conditions (e.g., diabetes, heart disease)?
Current Medications
List your current medications (name, dose, frequency).
Supplements and Natural Medicine
List your current supplements or natural medicines (name, dose, frequency).
Therapeutic Nutrition Assessment
Do you follow any special diet or nutrition plan?

Other
Describe your typical daily meals and snacks.
Digestive Health
Do you experience any digestive symptoms (e.g., nausea, constipation, diarrhea, bloating)?
Lifestyle and Functional Status
How would you describe your current level of physical activity?
Do you have any difficulties with daily living activities (e.g., bathing, dressing, mobility)?
Integrative Medicine History
Have you used any integrative or complementary therapies (e.g., acupuncture, massage, yoga, meditation, homeopathy)?
Medical Records Upload
Upload your medical records

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Goals
What are your main health goals or concerns?
Consent and Authorization
I confirm that the information I have provided is accurate to the best of my knowledge.
I consent to Sim Naturals Limited reviewing my medical records for the purpose of developing my personalized integrative care plan.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Click here to Complete your assesment
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SIM NATURALS LIMITED Comprehensive Integrative Oncology Assessment Form

Thank you for choosing Sim Naturals Limited. This assessment helps us understand your health, medical history, nutrition, and treatment journey so we can prepare a personalized integrative care plan before your consultation. Estimated completion time: 20–30 minutes.

Emergency Contact

Cancer Diagnosis

Clinical Risk Screening

Current Medical Treatment

Medical History

Current Medications

Supplements and Natural Medicine

Therapeutic Nutrition Assessment

Digestive Health

Lifestyle and Functional Status

Integrative Medicine History

Medical Records Upload

Goals

Consent and Authorization

Click here to Complete your assesment