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Medical Evaluation Form – Cancer

Medical Evaluation Form - Cancer

Thank you for your interest in our service.


In order for our medical team to evaluate whether or not you are eligible for treatment and recommend a relevant medical program and treatment for you, please fill in the form below to the best of your ability or with the help of your physician.

  • Name *

  • Date of Birth *

  • Country

  • Email *

  • Phone

  • Height

  • Unit

  • Weight

  • Unit

  • History and Diagnosis

  • What is your Primary diagnosis? *

  • When were you first diagnosed?

    MM

    DD

    YYYY

    If you don't remember the specific date, just fill in the year of diagnoses with or without month.

  • How was the disease diagnosed?

  • Please describe the progression of your condition from early symptoms until now.

  • Have you taken surgeries, chemotherapy or radiation therapy? If yes, what’s the program? (Medication, dosage and period, etc.)

  • Does anyone in your family have medical history relevant to your condition?

  • Symptoms

  • Please list your main complaint currently and all your current general condition: (appetite/ performance of daily activities/ fatigue/ vision/breathing/ chest pain/ headache/ dizziness/jaundice/ascites/eating problem etc.)

  • Has the disease spread to other organs? If yes, please specify where and the date it was discovered.

  • Medications

  • Please list any medications that you are currently taking with dosage and effectiveness and / or side effects

  • What is the date of the last treatment? When is the next treatment scheduled?

  • Please list the diagnostic exams you have had along with date, results and if images are available on request.

  • Any medical records that you can send us will be helpful for your medical evaluation.

    Be sure to include with the forms the following information:

    Typed pathology reports

    Typed surgical reports, MRI reports

    Typed medical and treatment history summary

    Typed laboratory reports

    Typed radiology (x-ray, CT scans, ultrasound, bone scan prepared by your physician

    Most recent lab values (CBC w/Diff & chemistries, i.e. BUN, Cre. Ca+)

    Pathological paraffin tissue section

    (Please note: MRI scan is recommended within last 30 days)

    Medical records or recent oncological evaluation from your oncologist

  • File

  • File

  • File

  • File

  • File

  • Hypertension

  • Heart disease

  • Diabetes

  • CVA/ Stroke

  • Lung disease

  • Liver disease

  • Kidney disease

  • Fracture or break

  • Cancer or tumor

  • Inflammation or infection

  • Others

  • Other information

  • Is there a caregiver who can provide you with care and assistance during your stay at the hospital if necessary?

  • Do you smoke?

  • Are you currently using or ever used drugs or alcohol?

  • Do you have sleep apnea, chronic obstructive pulmonary disease or other condition that doesn't allow for general anesthesia?