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Cancer Care Questionnaire
1.
Name:
2.
Date and place of birth
3.
Relationship Status: Single, Married, Divorced, Widowed, etc:
4.
Living arrangements- live alone or with (Please specify)
Alone
Spouse
Roommate
Significant other
Mother
Father
Sibling
Children
Other (please specify)
5.
Profession:
6.
What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”.
7.
What is your current weight in pounds?
8.
What type of cancer were you diagnosed with?
9.
How long ago were you diagnosed?
10.
Has anyone in your family, friends and others around you been diagnosed with this type of cancer?
11.
Have you seen a Physician/ Oncologist for this particular concern? Name and specialty of the Physician.
12.
Do you take any prescription medication OR have you been treated for this concern? How long? (Please specify what kind and the dose)
13.
Do you, or have you ever self-medicated? What medication?
14.
Does this condition pose a threat to your life? Or to the life of others around you? Explain in detail?
15.
Would you be able to share medical records related to the above issue with me?
16.
Have you ever had any genetic testing done? (Ex: 23 & me or others) Please specify.
17.
Do you have any other test results you can share with me? (ex: food allergies, immune markers, etc)
18.
On a scale of 1-5 how much do you think this condition affects the following (with 1 =VERY LITTLE and 5= EXTREMELY Seriously ):
1
2
3
4
5
Ability to get out of bed easily and routinely
1
2
3
4
5
Ability to care for yourself, personal hygiene, daily routine care
1
2
3
4
5
Ability to work, do your job effectively
1
2
3
4
5
Ability to attend social events
1
2
3
4
5
Ability to have an intimate relationship
1
2
3
4
5
Ability to engage in LIGHT physical activity
1
2
3
4
5
Ability to engage in a MODERATE physical activity
1
2
3
4
5
Ability to engage in an INTENSE physical activity
1
2
3
4
5
Ability to sleep/ uninterrupted, peacefully and regularly
1
2
3
4
5
Ability to consume certain foods
1
2
3
4
5
Ability to consume certain beverages
1
2
3
4
5
Ability to consume certain Vitamins/ Supplements
1
2
3
4
5
Ability to consume certain medications
1
2
3
4
5
Ability to eliminate (regular bowel movements, urination)
1
2
3
4
5
Ability to have Children
1
2
3
4
5
19.
On a scale of 1-5 how would you rate the pain that this is causing you?
1
2
3
4
5
Overall Pain
1
2
3
4
5
Targeted pain
1
2
3
4
5
Daily
1
2
3
4
5
Occasionally
1
2
3
4
5
20.
How often do you experience pain associated with this condition/concern?
1
2
3
4
5
Weekly
1
2
3
4
5
Daily
1
2
3
4
5
Hourly
1
2
3
4
5
All the time- Never stops hurting
1
2
3
4
5
Never- I do not have any pain associated with this condition/concer
1
2
3
4
5
21.
Are you able to follow my recommendations and instructions to help you with this condition?
Yes
No
Not sure
22.
If you are NOT able to follow my recommendations, do you have someone to help you?
Yes
No
Not sure
23.
Who is your helper and can I communicate with them?
Yes
No
Not sure
24.
How reliable/available is your helper?
25.
Are you committed to make some necessary lifestyle changes in order to improve or eliminate this condition?
26.
Are you comfortable talking about this with others? Or is this kept quiet from others including your family and close friends? Why?
27.
In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
28.
In general, how would you rate your overall mental or emotional health?
Excellent
Very good
Good
Fair
Poor
29.
When was your last physical exam? results? Normal, concerns, please specify:
30.
Please provide information about your family
Genetic Disorders
Cancer
Diabetes
Cholesterol
Blood Pressure
Mental Health
Paternal Grandfather
-- Select an option --
Cystic Fibrosis
Parkinson's Disease
Kleinfelter's
Huntington's
Other
-- Select an option --
Breast Cancer
Lung Cancer
Prostate Cancer
Lymphoma (Hodgkins or non-Hodgkins)
Leukemia
Myeloma
Pancreatic Cancer
Brain Cancer
Skin Cancer
Other
-- Select an option --
Type I
Type II
-- Select an option --
High Cholesterol
-- Select an option --
High BP
Low BP
-- Select an option --
Depression
Anxiety
Bipolar Disorder
other
Paternal Grandmother
-- Select an option --
Cystic Fibrosis
Parkinson's Disease
Kleinfelter's
Huntington's
Other
-- Select an option --
Breast Cancer
Lung Cancer
Prostate Cancer
Lymphoma (Hodgkins or non-Hodgkins)
Leukemia
Myeloma
Pancreatic Cancer
Brain Cancer
Skin Cancer
Other
-- Select an option --
Type I
Type II
-- Select an option --
High Cholesterol
-- Select an option --
High BP
Low BP
-- Select an option --
Depression
Anxiety
Bipolar Disorder
other
Maternal Grandfather
-- Select an option --
Cystic Fibrosis
Parkinson's Disease
Kleinfelter's
Huntington's
Other
-- Select an option --
Breast Cancer
Lung Cancer
Prostate Cancer
Lymphoma (Hodgkins or non-Hodgkins)
Leukemia
Myeloma
Pancreatic Cancer
Brain Cancer
Skin Cancer
Other
-- Select an option --
Type I
Type II
-- Select an option --
High Cholesterol
-- Select an option --
High BP
Low BP
-- Select an option --
Depression
Anxiety
Bipolar Disorder
other
Maternal Grandmother
-- Select an option --
Cystic Fibrosis
Parkinson's Disease
Kleinfelter's
Huntington's
Other
-- Select an option --
Breast Cancer
Lung Cancer
Prostate Cancer
Lymphoma (Hodgkins or non-Hodgkins)
Leukemia
Myeloma
Pancreatic Cancer
Brain Cancer
Skin Cancer
Other
-- Select an option --
Type I
Type II
-- Select an option --
High Cholesterol
-- Select an option --
High BP
Low BP
-- Select an option --
Depression
Anxiety
Bipolar Disorder
other
Father
-- Select an option --
Cystic Fibrosis
Parkinson's Disease
Kleinfelter's
Huntington's
Other
-- Select an option --
Breast Cancer
Lung Cancer
Prostate Cancer
Lymphoma (Hodgkins or non-Hodgkins)
Leukemia
Myeloma
Pancreatic Cancer
Brain Cancer
Skin Cancer
Other
-- Select an option --
Type I
Type II
-- Select an option --
High Cholesterol
-- Select an option --
High BP
Low BP
-- Select an option --
Depression
Anxiety
Bipolar Disorder
other
Mother
-- Select an option --
Cystic Fibrosis
Parkinson's Disease
Kleinfelter's
Huntington's
Other
-- Select an option --
Breast Cancer
Lung Cancer
Prostate Cancer
Lymphoma (Hodgkins or non-Hodgkins)
Leukemia
Myeloma
Pancreatic Cancer
Brain Cancer
Skin Cancer
Other
-- Select an option --
Type I
Type II
-- Select an option --
High Cholesterol
-- Select an option --
High BP
Low BP
-- Select an option --
Depression
Anxiety
Bipolar Disorder
other
Sibling 1
-- Select an option --
Cystic Fibrosis
Parkinson's Disease
Kleinfelter's
Huntington's
Other
-- Select an option --
Breast Cancer
Lung Cancer
Prostate Cancer
Lymphoma (Hodgkins or non-Hodgkins)
Leukemia
Myeloma
Pancreatic Cancer
Brain Cancer
Skin Cancer
Other
-- Select an option --
Type I
Type II
-- Select an option --
High Cholesterol
-- Select an option --
High BP
Low BP
-- Select an option --
Depression
Anxiety
Bipolar Disorder
other
Sibling 2
-- Select an option --
Cystic Fibrosis
Parkinson's Disease
Kleinfelter's
Huntington's
Other
-- Select an option --
Breast Cancer
Lung Cancer
Prostate Cancer
Lymphoma (Hodgkins or non-Hodgkins)
Leukemia
Myeloma
Pancreatic Cancer
Brain Cancer
Skin Cancer
Other
-- Select an option --
Type I
Type II
-- Select an option --
High Cholesterol
-- Select an option --
High BP
Low BP
-- Select an option --
Depression
Anxiety
Bipolar Disorder
other
Sibling 3
-- Select an option --
Cystic Fibrosis
Parkinson's Disease
Kleinfelter's
Huntington's
Other
-- Select an option --
Breast Cancer
Lung Cancer
Prostate Cancer
Lymphoma (Hodgkins or non-Hodgkins)
Leukemia
Myeloma
Pancreatic Cancer
Brain Cancer
Skin Cancer
Other
-- Select an option --
Type I
Type II
-- Select an option --
High Cholesterol
-- Select an option --
High BP
Low BP
-- Select an option --
Depression
Anxiety
Bipolar Disorder
other
Sibling 4
-- Select an option --
Cystic Fibrosis
Parkinson's Disease
Kleinfelter's
Huntington's
Other
-- Select an option --
Breast Cancer
Lung Cancer
Prostate Cancer
Lymphoma (Hodgkins or non-Hodgkins)
Leukemia
Myeloma
Pancreatic Cancer
Brain Cancer
Skin Cancer
Other
-- Select an option --
Type I
Type II
-- Select an option --
High Cholesterol
-- Select an option --
High BP
Low BP
-- Select an option --
Depression
Anxiety
Bipolar Disorder
other
Sibling 5
-- Select an option --
Cystic Fibrosis
Parkinson's Disease
Kleinfelter's
Huntington's
Other
-- Select an option --
Breast Cancer
Lung Cancer
Prostate Cancer
Lymphoma (Hodgkins or non-Hodgkins)
Leukemia
Myeloma
Pancreatic Cancer
Brain Cancer
Skin Cancer
Other
-- Select an option --
Type I
Type II
-- Select an option --
High Cholesterol
-- Select an option --
High BP
Low BP
-- Select an option --
Depression
Anxiety
Bipolar Disorder
other
Sibling 6
-- Select an option --
Cystic Fibrosis
Parkinson's Disease
Kleinfelter's
Huntington's
Other
-- Select an option --
Breast Cancer
Lung Cancer
Prostate Cancer
Lymphoma (Hodgkins or non-Hodgkins)
Leukemia
Myeloma
Pancreatic Cancer
Brain Cancer
Skin Cancer
Other
-- Select an option --
Type I
Type II
-- Select an option --
High Cholesterol
-- Select an option --
High BP
Low BP
-- Select an option --
Depression
Anxiety
Bipolar Disorder
other
Other (please specify)
31.
Please provide information about your family
Alcohol Consumption
Tobacco (Cigarettes, Pipes etc)
Tobacco (Chew, e-cigarettes)
Paternal Grandfather
-- Select an option --
Never
On occasion
Monthly (1-2)
Weekly (1-4)
Daily (less than 2)
Daily (more than 2)
-- Select an option --
Never smoker
Former smoker
Current smoker
-- Select an option --
Never user
Former user
Current user
Paternal Grandmother
-- Select an option --
Never
On occasion
Monthly (1-2)
Weekly (1-4)
Daily (less than 2)
Daily (more than 2)
-- Select an option --
Never smoker
Former smoker
Current smoker
-- Select an option --
Never user
Former user
Current user
Maternal Grandfather
-- Select an option --
Never
On occasion
Monthly (1-2)
Weekly (1-4)
Daily (less than 2)
Daily (more than 2)
-- Select an option --
Never smoker
Former smoker
Current smoker
-- Select an option --
Never user
Former user
Current user
Maternal Grandmother
-- Select an option --
Never
On occasion
Monthly (1-2)
Weekly (1-4)
Daily (less than 2)
Daily (more than 2)
-- Select an option --
Never smoker
Former smoker
Current smoker
-- Select an option --
Never user
Former user
Current user
Father
-- Select an option --
Never
On occasion
Monthly (1-2)
Weekly (1-4)
Daily (less than 2)
Daily (more than 2)
-- Select an option --
Never smoker
Former smoker
Current smoker
-- Select an option --
Never user
Former user
Current user
Mother
-- Select an option --
Never
On occasion
Monthly (1-2)
Weekly (1-4)
Daily (less than 2)
Daily (more than 2)
-- Select an option --
Never smoker
Former smoker
Current smoker
-- Select an option --
Never user
Former user
Current user
Sibling 1
-- Select an option --
Never
On occasion
Monthly (1-2)
Weekly (1-4)
Daily (less than 2)
Daily (more than 2)
-- Select an option --
Never smoker
Former smoker
Current smoker
-- Select an option --
Never user
Former user
Current user
Sibling 2
-- Select an option --
Never
On occasion
Monthly (1-2)
Weekly (1-4)
Daily (less than 2)
Daily (more than 2)
-- Select an option --
Never smoker
Former smoker
Current smoker
-- Select an option --
Never user
Former user
Current user
Sibling 3
-- Select an option --
Never
On occasion
Monthly (1-2)
Weekly (1-4)
Daily (less than 2)
Daily (more than 2)
-- Select an option --
Never smoker
Former smoker
Current smoker
-- Select an option --
Never user
Former user
Current user
Sibling 4
-- Select an option --
Never
On occasion
Monthly (1-2)
Weekly (1-4)
Daily (less than 2)
Daily (more than 2)
-- Select an option --
Never smoker
Former smoker
Current smoker
-- Select an option --
Never user
Former user
Current user
Sibling 5
-- Select an option --
Never
On occasion
Monthly (1-2)
Weekly (1-4)
Daily (less than 2)
Daily (more than 2)
-- Select an option --
Never smoker
Former smoker
Current smoker
-- Select an option --
Never user
Former user
Current user
Sibling 6
-- Select an option --
Never
On occasion
Monthly (1-2)
Weekly (1-4)
Daily (less than 2)
Daily (more than 2)
-- Select an option --
Never smoker
Former smoker
Current smoker
-- Select an option --
Never user
Former user
Current user
Other (please specify)
32.
Do you consume:
Frequency
Amount Daily when applicable
Amount Weekly when applicable
Breakfast
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Mid morning snack
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Lunch
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Afternoon snack
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Dinner
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Evening snack
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Vegetables
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Fruits
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Red meat (Beef, Pork, Lamb, Buffalo, Venison, other wild game)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Poultry (Chicken, Turkey)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Fish (Salmon, Cod, Haddock etc)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Shellfish (Shrimp, Lobster, etc)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Dairy (All milk-based such as milk, cream, cheese etc)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Eggs (Whole and Whites only)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Nuts (Almonds, Walnuts, Pistachios, Peanuts, Cashews etc)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Seeds (Flax, Sesame, Chia, Hemp, etc)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Soy based products (Tofu, soy milk, Tempe etc)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Grains and grain containing products (Bread, rolls, cereals, pasta, crackers etc)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Baked goods, pastries and sweets (Cakes, cookies, danishes etc)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Plain Water (No bubbles, flavors)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Juice
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Coffee (caffeinated)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Coffee (Decaf)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Tea (Caffeinated)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Tea (Herbal, Caffeine-free)
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Alcoholic beverages
-- Select an option --
Never
On occasion
Daily
-- Select an option --
0-1 a day
1-3 a day
4-6 a day
More than 6 a day
-- Select an option --
0-1 per week
1-3 per week
4-6 per week
6-8 per week
More than 8 per week
Other (please specify)
33.
Please list any nutritional supplements you are currently taking.
Vitamins (i.e. Vitamin C, A, D etc)
Herbal supplements (i.e. Ginseng, Burdock Root etc)
Minerals (Calcium, Potassium, Magnesium etc)
Amino Acids (Glutamine, Tyrosine, Branched chained amino acids, etc)
Colon cleanse
Liver detox
Candida detox
Total body detox
Fiber supplements
Kidney cleanse
Diuretics
Laxatives
34.
Do you have a regular bedtime and waking time? (Please specify)
In Bed by:
Wake up by:
Varies
35.
Do you sleep in on weekends?
Yes
No
Sometimes
36.
Your Sleep Pattern
I wake up often
I toss and turn
I sleep soundly
If I wake up, I fall back asleep easily
If I wake up, I toss and turn
Other (please specify)
37.
Have you or do you ever take sleeping aid (prescription or over the counter)?
Yes
No
Sometimes
38.
Please define your goals?
Next 12 weeks
Short-term: next 6-12 months
Mid-term: next 3 years
Long term: next 5 years
Life time
39.
In the space provided, please provide a food log for the last 3 days
Breakfast
Morning snack
Lunch
Afternoon snack
Dinner
Evening snack
Other
Breakfast
Morning snack
Lunch
Afternoon snack
Dinner
Evening snack
Other
Breakfast
Morning snack
Lunch
Afternoon snack
Dinner
Evening snack
Other
40.
SPECIFICALLY what would you like me to do for you immediately?
41.
Do you know your
Blood Pressure
Total Cholesterol
HDL (Good Cholesterol)
LDL (Bad Cholesterol)
Blood Type (A, B, AB, O)
