New Patient Form
Prospective new patients for Hope 4 Cancer should complete the following information. A physician will review this and arrange for a private consultation. Please complete all of the information found on this form.
Your Health is Our Top Priority
Personal Information

Name   Date (MM/DD/YYYY)
    City
State Telephone: (required) Zip
Date Of Birth ( MM/DD/YYYY) BirthPlace
Sex Male Female
Status Single Married Divorced Widow(er) Occupation
Date of Last Examination ( MM/DD/YYYY)  Email (required):
List Your Symptoms List Your Complaints and when they started
Routine CheckUp-No Symptoms

Family History

 
If Living
If Deceased
Age Health Condition Age at Death Cause
Father
Mother
Brother or Sister 1
2
3
4
5
Husband or Wife
Son or Daughter 1
2
3
4
5
6
 

 

Weight:
NOW Years ago Maximum specify how many years back


Has there been any recent changes in:
Your appetite or eating habits Yes No
Your bowel movements or stools Yes No
Habits
Exercise Adequate Yes No
How do you Exercise?
Sleep well? Yes No
Average 8 hours? Yes No
Bowels move regularly? Yes No
Diet well balanced? Yes No
Meat: servings/day
Fruits: servings/day
Vegetables: servings/day
Eggs: per day
Bread: slices/day
Potatoes: servings/day
Cereals: servings/day
Salt light moderate heavy
Spices, pepper, pickles, etc. light moderate heavy
Milk: glasses/day
Coffee: cups/day
Tea: cups/day
Soft Drinks per day
Water glasses/day
Alcoholic Beverages Never Rarely Moderate Daily
Have you ever been treated for alcoholism Yes No
Tobacco: packs per day Cigarettes: packs per day
Cigars Pipe Chewing Tobacco Snuff
Drugs:
Laxatives Never Occasionally Frequently Daily
Vitamins: Never Occasionally Frequently Daily
Sedatives: Never Occasionally Frequently Daily
Tranquillizers: Never Occasionally Frequently Daily
Sleeping pills, etc: Never Occasionally Frequently Daily
Aspirin, etc.: Never Occasionally Frequently Daily
Cortisone, ACTH: Never Occasionally Frequently Daily
Thyroid: Never Yes in the Past Now
Now on: gr. Daily
Appetite suppressants: Never Occasionally Frequently Daily
Have you ever been treated for drug habits Yes No
Have you ever taken insulin, tablets for diabetes Yes No
Hormone shots or tablets Yes No
Work: hrs/day indoors hrs/day outdoors
Do you like to work? Yes No
 

Women Only
Menstrual History
Age of onset
Regular Yes No
Cycle days(f rom start to start)
Usual duration days
Heavy Medium Light
Pains or cramps Yes No
Date of last period
How many children born alive
How many premature
How many Cesarean Sections
How many miscarriages
Any complications with any pregnancy Yes No