• Shimotakaido 5-4-10, Suginami-ku, Tokyo

Medical Questionnaire for Cancer Treatment

Home
/
Medical Questionnaire for Cancer Treatment

For those wishing to receive cancer treatment, please fill out and submit the questionnaire before your consultation. Sharing your information in advance will help shorten the consultation time and contribute to a more in-depth and productive session.

※Disclaimer: This form is used to collect information about patients and used for internal purposes only. The information you supply is confidential and will be treated accordingly.

    Patient Information：
    Date of Entry：

    Your Information：

    Gender：
    Date of Birth：





    Cancer History：
    Cancer Location： (Please check all that apply)
    Cancer Stage：
    Cancer therapy：
    Please select the cancer therapy that you have taken：

    Surgery：

    Year：
    Location：

    Chemotherapy：

    Duration：
    Medication：
    Effectiveness：
    Side Effects：

    Radiotherapy：

    The type(s) of radiotherapy：
    Duration：
    Location：
    Effectiveness：
    Side Effects：

    Immunotherapy：

    The type(s) of immunotherapy：
    Duration：
    Immune Checkpoint Inhabitors：

    Current Cancer Medications：

    Other Medications：

    Please list the medications you're taking, including the name and dosage(amount of active ingredient e.g. mg).
    Blood thinners：
    Blood thinning supplements：
    Hypertension：
    Diabetes：
    Dyslipidemia/Cholesterol：
    Other：

    Data from Other Hospitals：


    If you have medical records from another hospital, please upload them here.
    Attachment file：

    Metastasis：

    Pain Assessment：
    Location of Pain：
    On a scale of 1 to 10, how would you rate the pain in that area? (1= No pain, 10 = Worst pain imaginable)
    Type of Pain：
    Duration and Frequency：
    Any Relief Measures：

    Social History
    Alcohol： ( )
    Tobacco： ( )

    Medical History
    Past Medical History： (Please check any medical problems that you have had in the past)

    Allergies：
    Food：
    Medication：

    Assessment of Daily Living Activities
    Mobility： If no, please specify the type
    Catheter Use： If yes, please specify the type

    Family History of Cancer：




    Emergency Contact：



    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.

    How did you hear about our clinic?

    If you select other, please specify how you found out about the clinic.

    Thank you very much for your cooperation.