Thank Patient Questionnaire – CHIPSA Hospital: Gerson Therapy Center Cancer Treatment

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First Name *
Last Name *

Email *

Best Contact Phone # *

Who will the patient be?

Myself Mother or FatherSon or DaughterLoved one or friend

Patient's Age

Type of Cancer

How long has the patient had cancer?

What General Stage Cancer?

Stage 1Stage 2Stage 3Stage 4

Has the patient had Chemotherapy or Radiation?

Yes ChemoYes RadiationBothNone

Any pre existing medical conditions?

Do you have any pains?

Describe your symptoms:

Any prescribed medications supplements?

Current occupation?

Do you have life insurance

YesNo

Can you travel out of your state/province?

YesNo

How soon would you like to arrive for treatment?

24-48 hoursWithin 1 weekWithin 2 weeksWithin 30 days30 Days+

Extra Notes

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