Name Date

When were you diagnosed with cancer?

What is your original diagnosis?

What is your current diagnosis?

Where is the original site of your cancer?

What type of cancer is it?

What parts of the body has it spread to?

What is you current prognosis?

Please list all medical treatments given in the last two years.

Please list any surgeries you have had.

List current nutritional supplements being taken.

List all alternative therapies currently being done (massage, colonics, etc.)

What is your current pain level?

How much sleep are you getting per night?

Please list your history of chemo & radiation treatments.

Are you still doing chemo or radiation, if yes, how many sessions do you have left?

Who is the physician that diagnosed the cancer & the date?