About Cancer Prevention Plan

With a strong family history of cancer, I was determined to find a better way than to just give into my genes and wait my turn.  I chose a career in cancer research with the initial goal to “cure” cancer. But I have come to conclude that the best approach is PREVENT cancer BEFORE it has a chance. Or at the very least, delay its onset, with better predicted outcomes if it occurs.

The main goal of the Cancer Prevention Program is to arm your body’s defense mechanism and your immune system to keep cancer at the door, to reduce the risk  of getting cancer, OR significantly delay the onset of genetically determined cancers, and improved prognosis and outcomes in the event of onset.

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* 1. Name:

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* 2. Date and place of birth

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* 3. Estimated weight and estimated height at age 15:

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* 4. 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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* 5. What is your current weight in pounds?

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

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* 7. Do you have children? How many?

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

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* 9. Where do you live?

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* 10. Profession:

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* 11. How far do you live from work and how do you get to work?

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

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

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* 14. How long has it been since your most recent visit with your healthcare provider?

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* 15. During your most recent visit, did you talk with your healthcare provider about any health questions or concerns?

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* 16. If you answered YES to Q.15, please explain

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* 17. When was your last physical exam? Results? Normal, concerns, please specify:

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* 18. Please provide the following information below:

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

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* 20. Do you have any reason(s) to believe that you have risk factors for Cancer?

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

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

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* 26. Have you or anyone in your family been exposed to:

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* 27. If you checked any of the boxes above, please provide details (Who, when, where?)

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

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* 31. What do you most often do for exercise?

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* 32. How many hours a day do you spend sitting?

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* 33. How many hours a night do you sleep?  

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

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* 35. Do you sleep in on weekends?

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* 36. Your Sleep Pattern

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

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* 38. List 5 of your favorite hobbies?

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* 39. How many hours a day do you spend watching TV

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* 40. How many hours a day do you spend in front of a computer?

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* 41. How often do you attend social events, with friends, family, etc? (movies, dinners, parties, etc)

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* 42. How would you like to prioritize your Cancer Prevention Plan?

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

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

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* 45. Please define your goals?

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* 46. Can you follow the program that we design for you independently? If not, do you have someone to support you?

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

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

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

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