Patients and Caregivers Pre Admission


Patients And Caregivers Pre Admission

  • Treatment History

    Please list the chronological history of the present illness (dates and the treatments including alternative therapies in addition to surgeries, chemotherapy, radiation). Include important scan reports (those that diagnosed or showed growth or shrinkage of disease).
  • Please list current program including mainstream, complementary, alternative treatments (please include list of supplements
  • Please select all that apply
  • Please select all that apply
  • Please check the statement which best describes your current physical status
  • Part One

    Please take a few minutes to answer the following questions. Your answers will set the “baseline” for your quality of life measures upon your arrival in our program. Please answer all the questions, even if your answer is a quick “guess”.
  • Part Two

    Check the box next to the closest answer to each question.
  • Part Three

    Please select a number you feel matches the scale for the following questions.
  • 1 meaning never - 7 meaning continually
  • 1 meaning Not well - 7 meaning Very well
  • 1 meaning Continually - 7 meaning Never
  • 1 meaning Able - 7 meaning Unable
  • 1 meaning Not At All - 7 meaning A Good Deal
  • 1 meaning Extremely Poor - 7 meaning Extremely Well
  • 1 meaning Very Able - 7 meaning Not Able
  • 1 meaning No hardship - 7 meaning Tremendous hardship
  • 1 meaning Always - 7 meaning Never
  • 1 meaning Very dissatisfied - 7 meaning Very satisfied
  • 1 meaning Not At All - 7 meaning Very uncomfortable
  • 1 meaning Not At All - 7 meaning Completely
  • 1 meaning Completely - 7 meaning None At All
  • 1 meaning Tremendous hardship - 7 meaning No hardship
  • 1 meaning None - 7 meaning All Of It
  • 1 meaning Not at all - 7 meaning Very Willing
  • 1 meaning Constant - 7 meaning None
  • 1 meaning Completely Terrified - 7 meaning Totally Unafraid
  • 1 meaning Not willing - 7 meaning Very willing
  • 1 meaning None of it - 7 meaning All of it
  • 1 meaning Complete Confidence - 7 meaning No confidence
  • 1 meaning Very Well - 7 meaning Terrible
  • Part Four

  • (This exercise is optional and may seem “silly” but is in fact a form of “qualitative research” — Please give it a try!)