Adjunctive Cancer Support Registration

Please note: This is not a program to cure cancer. It is a lifestyle management program aiming to improve the quality of life only. Patient enrolled in this program should not cease any conventional cancer treatment therapy currently undergoing or proposed by their treating specialist, including but not limited to chemotherapy, radiation therapy or any other therapy. Undertaking this program does not alter your prognosis or orthodox management.

Personal Details

Patient's Name(Required)

Prefix First Last

Address(Required)

Street Address Suburb State Postcode Country

Mobile Number(Required)

Email(Required)

Date of Birth

Medicare

Please enter your medicare number, followed by your reference number, then expiry date.

Doctor's Name:

Current GP Doctor

*If you are seeking adjunctive cancer treatment, you will need to continue to see your current Medical Practitioners. This could be your local medical centre that you are thinking of attending.

Current Doctor Name(Required)

Current Doctor's Email(Required)

Practice Name

Practice Location(Required)

Current Oncologist/Specialist

Current Oncologist/Specialist Email(Required)

Oncologist's Practice Name

Oncologist's Practice Location

Emergency Contact

Name

Contact Number

Do you have an advanced health directive?

Yes

If yes, please provide this to the clinic on your first visit.

Cancer

Which stage of cancer?

In Remission / No Existing Disease

Stage 1

Stage 2

Stage 3

Stage 4

Type of Cancer

Metastasis if any:

Other relevant information:

Current treatment:

Pain Score

10 being the most pain

Fatigue Level

10 being the most tired

Inactivity Level

10 being the least active

Total Score

History of symptoms and events

(In time order)

Order of Investigations

(Scans, CT, Biopsies etc. in time order)

Treatment so far

(Surgery, Chemotherapy, Radiotherapy and Alternative including Oncologists/Surgeons, treatment outcomes and when completed)

Remission or reoccurrence history

(New Cancer or secondaries)

Are there any particular treatments or advice you have come to IMH Gold Coast for?

Previous Illness

Health Concerns / Symptoms / Diagnosed Conditions. Please list in time order.

Previous Surgery

Please list in time order.

Current Medications and Supplements:

Diet History

Breakfast and Morning Tea

Lunch and Afternoon Tea

Dinner and Late Supper

Any Fasting

Food Intolerances

How is your appetite?

Good/Bad?

Do you have Nausea?

Allergies to medications, food or chemicals?

Sleep History

Quality of Sleep

What time do you go to bed?

How long does it take you to fall asleep?

Do you wake up in the night? If so, how often and at what times?

Do you feel refreshed upon waking?

Do you take any sleep aids/drugs?

Computer/iPads/TV before bed?

Family History

Racial Heritage

Genetic or Familial Illness

Family History of Cancers?

History of Chronic or Viral Infections

Tick Bites

Viruses/EBV

Hepatitis?

Other

Previous Vaccinations

Occupation

Is your work stressful?

Stressors

Family / Domestic / Kids

Psychological, childhood traumas or assaults

Prolonged Bereavement

Any particularly stressful or emotionally traumatic event within a few years of diagnosis?

Exposure to Toxins (radiation / Mercury / chemicals )?

Dental History – any persistent dental infections / amalgams / root canals ?

Exercise History

How often and what type?

Relaxation

Meditative Practice e.g. mindfulness, yoga, Tai Chi, meditation, prayer

What do you do to relax or for other joyful activities?

Social History

Who do you live with?

Smoking history Inc. current & previous?

Alcohol history Inc current & previous?

Please sign below to confirm that you acknowledge and accept the New Patient Consultation Fee of $560 and confirm the above details are true and accurate. Please also note that our doctors support conventional cancer management and may also refer you to a suitable oncologist if you do not have one. One of our clinical staff members may call you in advance of the consult to discuss regarding our treatment process and follow up to see if you have any queries. Please also note that we require 24 hours’ notice for cancellation of appointments. Failure to do this will result in a charge of 100% of the consultation fee.

Signature(Required)

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