Date of Entry
Your Information Name Gender Male Female Date of Birth ( years old) Nationality
Height cm Weight Previously kg → Now kg (Change kg)
Address Phone Number Email Address
Cancer History Cancer Location (Please check all that apply) Breast Lung Prostate Colorectal Stomach Liver Pancreas Skin Brain Bladder Blood Other Cancer Stage —Please choose an option— Stage 0 (Carcinoma in situ) Stage I Stage II Stage III Stage IV Unknown Cancer therapy Please select the cancer therapy that you have taken Surgery Yes No Year Location Chemotherapy Yes No Duration From To Medication Alkylating Agents Antimetabolites Anti-Tumor Antibiotics Topoisomerase Inhibitors Mitotic Inhibitors Other Effectiveness —Please choose an option— Good Poor No Change Side Effects Vomiting/Nausea Hair Loss Weight Loss Diarrhea Constipation Numbness Anemia Infection Bleeding Mouth Ulcers Skin Disorders Nail Changes Other
Radiotherapy Yes No The type(s) of radiotherapy Electron Beam X-ray (IMRT/IGRT) CyberKnife Gamma Knife Proton Beam Heavy Ion Beam Interstitial Brachytherapy Intracavitary Brachytherapy Internal Radiation Therapy Duration From To Location Effectiveness —Please choose an option— Good Poor No Change Side Effects Nausea Hair Loss Diarrhea Mouth Ulcers Dry Mouth Taste Disturbance Difficulty Eating (Esophagitis) Pneumonia Skin Redness Skin Peeling Dermatitis (Sunburn-like) Other
Immunotherapy Yes No The type(s) of immunotherapy ANK DC (Dendritic Cells) Activated Lymphocytes Cancer Vaccine Duration From To Immune Checkpoint Inhabitors Opdivo Keytruda Yervoy Imfinzi Tecentriq Bavencio
Current Cancer Medications Yes No Cisplatin Doxorubicin Trastuzumab (Herceptin) Nivolumab (Opdivo) Tamoxifen Lapatinib Other
Other Medications Please list the medications you're taking, including the name and dosage(amount of active ingredient e.g. mg). Blood thinners Yes No Blood thinning supplements Yes No Hypertension Yes No Diabetes Yes No Dyslipidemia/Cholesterol Yes No Other
Data from Other Hospitals Yes No Medical Certificate Treatment Progress Record Blood Test Results X-ray CT Scan MRI PET Scan Surgical Record Radiation Therapy Record Chemotherapy Record If you have medical records from another hospital, please upload them here. Attachment file：
Metastasis Yes No Location
Pain Assessment Location of Pain None Chest Abdomen Back Joint Other On a scale of 1 to 10, how would you rate the pain in that area? —Please choose an option— 1 2 3 4 5 6 7 8 9 10 (1= No pain, 10 = Worst pain imaginable) Type of Pain Sharp Dull Throbbing Burning Other Duration and Frequency Constantly From Time to Time Other Any Relief Measures None NSAIDS Paracetamol Narcotic Other
Social History Alcohol Do not drink Drink ( —Please choose an option— 1 cup of sake 1 large bottle of beer 2/3 cup of shochu/awamori 1 double shot of whiskey 1/3 bottle of wine Drink more than this amount ) Tobacco Do not smoke Smoke ( cigarettes/day )
Medical History Past Medical History (Please check any medical problems that you have had in the past)None Anemia Anxiety Arthritis Asthma Allergies Clotting disorder Headaches Kidney disease Liver disease Osteoporosis Seizures Stroke HIV/AIDS Hypothuroidism Hypertension (high blood pressure) Hyperlipidemia (high cholesterol) Diabetes mellitus Heart problem Tuberculosis Ulcers Other
Allergies Food None Kiwi Banana Avocado Papaya Mango Melon Fig Cherry Egg Soy Wheat Peanuts Blue fish (e.g., mackerel, sardine) Other If you selected "Other," please specify the food. Severity of Allergic Reaction Mild Moderate Severe Medication None Aspirin (e.g., Bufferin) Ibuprofen (e.g., Brufen, Eve) Loxoprofen (e.g., Loxonin) Anesthetics (e.g., Xylocaine) Other If you selected "Other," please specify the medication. Severity of Allergic Reaction Mild Moderate Severe Antibiotics/Antifungals None Penicillin antibiotics Cephalosporins (e.g., Cefzon) Streptomycin Amikacin Aminoglycosides (excluding streptomycin, amikacin) Amphotericin B Other If you selected "Other," please specify the medication. Severity of Allergic Reaction Mild Moderate Severe Other None Latex Alcohol Iodine Severity of Allergic Reaction Mild Moderate Severe
Assessment of Daily Living Activities Mobility Yes No If no, please specify the type Walker Wheelchair Other Catheter Use Yes No If yes, please specify the type Urinary Catheter Feeding Tube Other
Family History of Cancer Father Location Mother Location Grandfather Location Grandmother Location Other
Emergency Contact Name Phone Number Email Address Relationship with Patient
Additional Notes Please include any additional information that may be relevant to your overall health condition
Source Questions Please select the purpose of your inquiry. Make an appointment Ask about consultation and treatment Inquire about fees and payment Ask about other matters Need immediate treatment
How did you hear about our clinic? Friend's referral Agent's referral Attended seminar Saw website Instagram Facebook WeChat Other If you select other, please specify how you found out about the clinic, and It would be helpful if you could provide the name of friend or agent who referred you.
