Patients and Caregivers Pre Admission Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*FaxEmail* Date of Birth* MM slash DD slash YYYY Age Place of birth Sex* Male Female Race Religion Marital Status* Spouse Emergency Contact*Present Illness* Diagnosis*HistologyDate of Original Diagnosis MM slash DD slash YYYY Stage Treatment HistoryPlease 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 The Date Followed By The EventCurrent treatment regimenPlease list current program including mainstream, complementary, alternative treatments (please include list of supplementsCurrent ConditionPlease select all that apply Pain Constipation Jaundice Anemia Loss of appetite Additional Comments Explaining Current ConditionPersonal HistoryPlease select all that apply Coronary Heart Disease High Blood Pressure Diabetes Stroke Rheumatoid Arthritis Autoimmune Disease Malaria Irritable Bowel Crohn’s Disease Depression Anxiety Please Describe Any Additional Personal History AfflictionsPerformance StatusPlease check the statement which best describes your current physical status Normal activity Symptoms but ambulatory In bed less than 50% of the time In bed more than 50% of the time Completely bedridden Part OnePlease 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”.Which of the following best describes your level of activity today? Mark the box with an “X”. Normal activity Symptoms but ambulatory In bed less than 50% of the time In bed more than 50% of the time Completely bedridden Part TwoCheck the box next to the closest answer to each question.How in control of your health do you feel? Totally Reasonably So-So Not very Not at all How would you rate your physical health? Excellent Second Choice Good Fair Poor How much pain do you have? None Almost none Some Quite a lot Too much to bear How would you rate your mood? Great Pretty good Fair Not good Terrible How would you rate your confidence? Completely Solid Pretty good So-So Not good Terrible How much do you worry about your illness? Not at all Very little Some Quite a bit It’s all I do How much support do you get from your family? Total Quite a bit Some Not very much None Part ThreePlease select a number you feel matches the scale for the following questions.Most people experience some feelings of depression at times. Rate how often you feel these feelings.1 meaning never - 7 meaning continually1234567How well are you coping with your everyday stress?1 meaning Not well - 7 meaning Very well1234567How much time do you spend thinking about your illness?1 meaning Continually - 7 meaning Never1234567Rate your ability to maintain your usual recreation or leisure activities.1 meaning Able - 7 meaning Unable1234567Has nausea affected your daily functioning?1 meaning Not At All - 7 meaning A Good Deal1234567How well do you feel today?1 meaning Extremely Poor - 7 meaning Extremely Well1234567Do you feel well enough to make a meal or do minor household repairs today?1 meaning Very Able - 7 meaning Not Able1234567Rate the degree to which your illness has imposed a hardship on those closest to you in the past two weeks.1 meaning No hardship - 7 meaning Tremendous hardship1234567Rate how often you feel discouraged about your life.1 meaning Always - 7 meaning Never1234567Rate your satisfaction with your work and your jobs around the house in the past month.1 meaning Very dissatisfied - 7 meaning Very satisfied1234567How uncomfortable do you feel today?1 meaning Not At All - 7 meaning Very uncomfortable1234567Rate how disruptive your illness has been to those closest to you in the last two weeks.1 meaning Not At All - 7 meaning Completely1234567How much is pain or discomfort interfering with your daily activities?1 meaning Completely - 7 meaning None At All1234567Rate the degree to which your disease has posed a hardship on you, personally, in the past two weeks.1 meaning Tremendous hardship - 7 meaning No hardship1234567How much of your usual household tasks are you able to complete?1 meaning None - 7 meaning All Of It1234567Rate how willing you were to see and spend time with those closest to you in the last two weeks?1 meaning Not at all - 7 meaning Very Willing1234567How much nausea have you had in the last two weeks?1 meaning Constant - 7 meaning None1234567Rate the degree to which you are frightened of the future.1 meaning Completely Terrified - 7 meaning Totally Unafraid1234567Rate how willing you were to see and spend time with friends in the past two weeks.1 meaning Not willing - 7 meaning Very willing1234567How much of your pain or discomfort over the past 2 weeks was related to your illness?1 meaning None of it - 7 meaning All of it1234567Rate your confidence in your prescribed course of treatment.1 meaning Complete Confidence - 7 meaning No confidence1234567How well do you appear today?1 meaning Very Well - 7 meaning Terrible1234567Part FourWrite a little story, as if you were explaining the illness you are dealing with to a small child, and please feel free to write a happy ending.(This exercise is optional and may seem “silly” but is in fact a form of “qualitative research” — Please give it a try!) 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