Initial Assessment

//Initial Assessment
Initial Assessment 2017-08-02T00:17:55+00:00
We would like to understand your situation better beforehand. With this form you can send us important information about yourself. In order for us to process your request as best as possible, we kindly ask you to fill in all fields.

Patient data

Title
Mr.Mrs.

Name

Last name

Age

Email Address

Street

Zip Code

City

Country

Phone

Symptoms

What kind of cancer do you have?

When was the first diagnosis?

Are metastases known?
If yes, in which organs?

Therapies to date
(multiple selection by pressing [Ctrl] possible)

How would you describe your current state?

Do you feel pain? If yes, what kind and how intense is the pain?

Are you currently on any regular medication? If yes, which?

Are other ailments known aside from cancer? If yes, which?

Are you able to travel alone?

yesno - only with an escortno - only with an ambulance / medical accompaniment

Remarks