GENERAL and MEDICAL QUESTIONNAIRE

Please use red or green ink to complete this questionnaire. Thank you.

Important note: please attach a recent portrait about yourself

Name:
Maiden name:
Title:
Genre (Female/Male):
Address:
Telephone no:
Name of the closest relative (wife/husband, parents or child):
Telephone no of the closest relative:
Fax:
E-mail:
Date of Birth:
Age:
Place of Birth:
Nationality:
Passport number:
Marital Status:
Children/ages:
Occupation:
Height:
Weight:
Any hobbies?
Exercise activities?
Date of last fever:
Average energy level:
Level of general motivation/inspiration:
Expected result of therapy:
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CURRENT DATES:
Current diagnosis:
Date of diagnosis:
Type of cancer/ Histology:
Primary tumour site:
Metastases location:
Stage and grade at diagnosis:
PREVIOUS HISTORY: date of onset, symptoms treatment/ tests/ surgeries
undertaken, scan results:

CURRENT MEDICATIONS: (medical and alternative/nutritional supplements,

etc.)

FAMILY HISTORY: (illnesses, health problems of mother/father/sisterrs/brothers/

grandparents)

CASE HISTORY FROM BIRTH: (include illnesses, medications, surgeries,

exposure to chemicals, smoking, alcohol, recreational drugs).
Childhood:

Adolescence:

Adulthood:
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CHECK LIST:
1. Where were you brought up?
2. Have you ever been exposed to the following:
Agricultural or environmental chemicals/toxins
Smoking (how long/how many)
Alcohol drinking (how much and how long for, are you still drinking).
3. Have you taken any recreational drugs - if so, which ones, how much and
for how long?
4. Medications
Previous medications (brand, dose and length of time prescribed)
5. Allergies - drugs/foods etc.
6. Do you have any root canal fillings, amalgam fillings, mouth abscesses?
(state how many).
Do you have any mouth-/throat-/teeth gum problems (ulcers, sore, throats,
condition of teeth and gums):
7. Do you have any visual or eye disturbances (give details and medication):
8. Do you have any ear problems (tinnitus, vertigo, earache, discharge):
9. Do you have any lymph node swelling: neck/ armpit/ groin/ other:
10. Do you suffer from catarrh (give details of medication):
11. Do you have any gastro-intestinal disorder?
Do you have any problem eating and/or drinking without discomfort?
12. Do you or have you in the past suffered with any acute bleeding of the
gastrointestinal tract?
13. Lungs - any pain, phlegm, fatigue, coughing?
14. Heart - do you suffer from of any heart irregularities, high blood
pressure etc? Give details/medications.
15. Kidneys do you have problems with your kidneys? If not, give details.
16. Do you suffer from fluid retention and where: ankles/ abdomen/ hands/
face/other.
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17. Are you suffering from any pain at the moment? If so, indicate where and
name any medication/ treatment taken.
18. Do you suffer from any muscular systems disorder: bone/muscle/joint
aches and pains: (give location, type of symptoms and occurrence plus
medication taken/treatment given).
Do you have any problem moving around easily?
Please write us if you need wheelchair, frame etc.
19. Do you suffer from any nervous disorders? State medication:
(fainting/ blackout/ seizures/ weakness/ paralysis/ numbness/ pins and needles/
tremors/ involuntary movement).
20.A. Did you suffer from any mental, emotional behavioral disorder?
20.B. Have you ever had psychological or psychiatrical treatment ?
(anxiety, panic attacks, any unexplainable fears, depression, personality disorder,
etc.) If yes, please describe.
21. Do you have any implants? (heart valves, hip replacements, breast
implants, teeth, wires from surgery)
22. Have you had any blood transfusions? (Give reason and dates)?
23. Do you have any organ transplants?
24. Have you had any bone marrow transplants?
25. Have you had any accidents or injuries, (give description, dates and
treatment given):
26. Give dates and any reaction to all vaccinations (if known):
27. FEMALE HISTORY
27/1. Details of menstruation:
(Year of onset/menopause, irregularities, length of cycle/flow etc)
27/2. Have you taken the contraceptive pill or been prescribed any other
type of hormonal treatment: (Give details of medication, length of time
prescribed, dates/year, side-effects etc.)

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27/3- Details of pregnancies and births with dates: Was birth

induced/forceps used/ Caesarian/ premature/ jaundice/ toxemia or other
complications during pregnancy?
27/4. Health of any offspring: (jaundice, colic, eczema, asthma, allergies,
ADHD, etc.)
27/5. Have you experienced any problems with the following and state the
date/year and any treatment given:
Miscarriages
Terminations
Complications
Infertility
Surgeries

date/year

Treatment

DIET
Diet as a child/adolescent: (including food habits):
Diet as an adult:
Current diet:
How many meals do you have a day?
How many cups of tea/coffee?
Do you have food cravings (give details, type of frequency and time of
day/month)?
Do you have food allergies (give details and symptoms)?
Do you have food intolerances or digestive difficulties (give details and
symptoms)?
What is your daily intake of alcohol?
What is your daily fluid intake (other than alcohol)?
Do you experience a lack/excess of appetite? (Please underline).
Give a detailed description of a normal daily eating plan for breakfast, lunch
and evening meal. Include all foods, drinks, snacks etc.
Breakfast:
Lunch:

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Dinner:
Others:

Thank you for your cooperation

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