Title Mr.Mrs.
Name
Last name
Age
Email Address
Street
Zip Code
City
Country
Phone
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) ChemotherapyOperationRadiationAntibody TherapyOtherNot sure
How would you describe your current state?100% normal, no complaints, no overt disease90% minimal disease symptoms80% normal performance with effort70% limited capacity, unable to work, no foreign aid needed60% occasional foreign aid50% nursing and hospital medical help, not permanently bedridden40% bedridden, special care is required30% seriously ill, hospital care necessary20% hospital care and supportive measures are required10% moribund, disease progressing rapidly
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
