About Cancer Control Plan

While I have lost many dear loved ones to cancer, I am very fortunate to know many amazing people in my life who have been diagnosed with cancer and are living very healthy, happy lives having put their cancer behind. If you are a cancer survivor, CONGRATULATIONS! I want to empower you to live your LIFE not your cancer.

The main goal of the Cancer Control Program is to continuously enhance your body’s defense mechanism and reinforce your immune system to keep cancer under control. This is aimed to reduce the risk of relapse, metastasis, or onset of secondary therapy related cancers, OR significantly delay relapse and improve prognosis and outcomes in the event of a relapse.

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* 1. Name:

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* 2. Date and place of birth

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* 3. Relationship Status: Single, Married, Divorced, Widowed, etc:

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* 4. Living arrangements- live alone or with (Please specify)

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* 5. Profession:

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* 6. What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”.

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* 7. What is your current weight in pounds?

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* 8. Do you know your

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* 9. Prescriptions or over the counter meds? Please specify

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* 10. What type of cancer were you diagnosed with?

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* 11. How long ago were you diagnosed?

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* 12. Have you been in Complete Remission (CR) OR Cancer Free? If yes, for how long?

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* 13. Have you been in Partial Remission (PR). If yes, for how long?

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* 14. Has anyone in your family, friends and others around you been diagnosed with this type of cancer?

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* 15. What is (are) the name(s) and specialty of the Physician(s), Oncologist(s), other specialist(s) who have cared for you?

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* 16. Did you take any prescription medication OR were you treated for this concern? How long? (Please specify what kind and the dose)

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* 17. Do you, or have you ever self-medicated? What medication?

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* 18. Would you be able to share medical records related to the above issue with me?

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* 19. Have you ever had any genetic testing done? (Ex: 23 & me or others) Please specify.

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* 20. Do you have any other test results you can share with me? (ex: food allergies, immune markers, etc)

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* 21. On a scale of 1-5 how much do you think this condition continues to affect the following (with 1 =VERY LITTLE and 5= EXTREMELY Seriously ):

  1 2 3 4 5
Ability to get out of bed easily and routinely
Ability to care for yourself, personal hygiene, daily routine care
Ability to work, do your job effectively
Ability to attend social events
Ability to have an intimate relationship
Ability to engage in LIGHT physical activity
Ability to engage in a MODERATE physical activity
Ability to engage in an INTENSE physical activity
Ability to sleep/ uninterrupted, peacefully and regularly
Ability to consume certain foods
Ability to consume certain beverages
Ability to consume certain Vitamins/ Supplements
Ability to consume certain medications
Ability to eliminate (regular bowel movements, urination)
Ability to have Children

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* 22. How often do you still experience any long-term effects associated with this condition/concern?

  1 2 3 4 5
Weekly
Daily
Hourly
All the time- the effects never diminished
Never- there are no continuing effects that I know of

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* 23. Are you able to follow my recommendations and instructions to help you reduce your risk of relapse, metastasis, OR secondary cancers?

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* 24. If you are NOT able to follow my recommendations, do you have someone to help you?

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* 25. Who is your helper and can I communicate with them?

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* 26. How reliable/available is your helper?

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* 27. Are you committed to make some necessary lifestyle changes in order to keep your cancer under control?

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* 28. Are you comfortable talking about this with others? Or is this kept quiet from others including your family and close friends? Why?

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* 29. In general, how would you rate your overall health?

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* 30. In general, how would you rate your overall mental or emotional health?

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* 31. When was your last physical exam? results? Normal, concerns, please specify:

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* 32. Please provide information about your family

  Genetic Disorders Diabetes Cardiovascular Disease
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Father
Mother
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Sibling 5
Sibling 6

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* 33. Has anyone one in your family had any of the following?

  Solid Tumors Hematologic Malignancies
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Maternal Aunt
Father
Mother
Maternal Cousin
Sister (s)
Brother(s)

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* 34. Please provide information about your family

  Alcohol Consumption Tobacco (Cigarettes, Pipes etc) Tobacco (Chew, e-cigarettes)
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Father
Mother
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Sibling 5
Sibling 6

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* 35. Do you consume:

  Frequency Amount Daily when applicable Amount Weekly when applicable
Breakfast
Mid morning snack
Lunch
Afternoon snack
Dinner
Evening snack
Vegetables
Fruits
Red meat (Beef, Pork, Lamb, Buffalo, Venison, other wild game)
Poultry (Chicken, Turkey)
Fish (Salmon, Cod, Haddock etc)
Shellfish (Shrimp, Lobster, etc)
Dairy (All milk-based such as milk, cream, cheese etc)
Eggs (Whole and Whites only)
Nuts (Almonds, Walnuts, Pistachios, Peanuts, Cashews etc)
Seeds (Flax, Sesame, Chia, Hemp, etc)
Soy based products (Tofu, soy milk, Tempe etc)
Grains and grain containing products (Bread, rolls, cereals, pasta, crackers etc)
Baked goods, pastries and sweets (Cakes, cookies, danishes etc)
Plain Water (No bubbles, flavors)
Juice
Coffee (caffeinated)
Coffee (Decaf)
Tea (Caffeinated)
Tea (Herbal, Caffeine-free)
Alcoholic beverages

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* 36. Please list any nutritional supplements you are currently taking.

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* 37. Do you have a regular bedtime and waking time? (Please specify)

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* 38. Do you sleep in on weekends?

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* 39. Your Sleep Pattern

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* 40. Have you or do you ever take sleeping aid (prescription or over the counter)?

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* 41. Do you currently do any Cardiovascular exercise? If yes, how many days a week and how long?

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* 42. What type of Cardiovascular exercise do you often do?

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* 43. Do you currently do any Strength & Conditioning exercises?

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* 44. How would you like to prioritize your Cancer Control Plan?

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* 45. Please define your goals?

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* 46. What does "being healthy" mean to you?

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* 47. What if anything limits you from being healthy?

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* 48. If you had one hour to do whatever you want, what would you do?

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* 49. In the space provided, please provide a food log for the past 3 days:
Breakfast
Morning Snack
Lunch
Afternoon Snack
Dinner
Evening Snack
Other

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* 50. SPECIFICALLY what would you like me to do for you immediately?

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* 51. Is there anything else you would like to share?

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