Confidential New Client Intake Form

The intention of this form is to provide an idea of where you are in your cancer experience, what you’re currently doing and what you are looking for. There are several approaches to cancer care that can be adapted to your needs and interests. Your answers to these questions will help me know how best to support you. Contrary to popular belief, the type of cancer and its stage are not always the key determinants of your choices. While important, YOU are the key to creating a treatment plan – not the cancer. Please take the time to fill this out thoughtfully. We will use it and I will keep it confidential.

Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
Age*
Please enter a number from 10 to 100.
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
Date Format: MM slash DD slash YYYY
Email
Referred By:
Treating Physician
Treating Physician's Phone
I’m here because I am looking for:
As part of this, I’m interested in learning about:
- Supplementing conventional treatment (chemotherapy, radiation and/or surgery) with dietary and lifestyle interventions that can improve outcomes while lessening side effects
- Non-‐toxic cancer treatment to replace conventional treatment
About my Cancer
Type
Stage (if known)
Date of Diagnosis (mm/yy)
Date Format: MM slash DD slash YYYY
Current or previous treatment (if any):
Challenging symptoms:
I am enhancing my treatment with: (supplements, therapies, interventions… if any)
Have you been diagnosed with any other medical conditions? Please explain & give dates of onset:
Prescription Drugs and Over-the-Counter Medications
Please check all type of medications or the conditions for which you are taking them
- Allergies
- Antacids
- Antibiotic
- Anti-‐depressant
- Anti-‐inflammatory
- Fibromyalgia
- Aspirin
- Blood-‐thinner
- Chemotherapy
- Cholesterol
- Diabetes
- GERD/indigestion
- Heart Medication
- Hypertension
- Hormone Therapy
- Laxatives
- Osteoporosis
- Pain Medication
- Steroids
- Thyroid
Other Medications You're taking:
I am on a special diet:
I eat or drink: (Rate the following on a 0‐10 scale where 0 is never and 10 is always)
Red Meat
Poultry
Pork
Lots of dark colored vegetables
Glasses of water/day:
(type of water consumed)
- Filtered
- Tap
Sugar: added to food
Sugar: sweets
Processed foods (packaged, frozen, canned)
Green Salads
Breads and pasta
Fruits
Fried foods
Artificial Sweeteners
Whole milk and dairy products
Green juicing/smoothies
Servings per Week
Coffee
Black tea
Herbal tea
Black tea
Soda pop
Alcohol
Fruit Juice
I take or use the following: (D=daily S=several times a week O=occasionally N=never)
Multi-vitamin
Multi-mineral
Vitamin C
Green Tea Extract
Fish oil
Co Q10
Vitamin A
Linoleic acid
Selenium
Garlic
Ginger
Curcumin
Vitamin D3
Green powder
Iodine
B Complex
Pancreatic Enzymes
Antioxidants
Probiotics
Vitamin E
Zinc
I take or use:
- Budwig protocol
- Essiac tea
- Beta--‐1 3D
- mushroom extract
- transfer factors
- Modified Citrus Pectin
- astragalus
- PolyMVA
- Laetrile
- DMSO
I take or use: Other
My doctor has me on physical/exercise restrictions:
I exercise:
- Daily
- A few times a week
- Occasionally
- Rarely
- Never
Typical length of exercise workout:
I do the following type(s) of exercise:
Dentistry
Number of cavities with silver fillings
Number of root canals
Number of wisdom teeth extraction
Significant gum problems
- Yes
Immune System
I frequently have colds, sore throats, sinus congestion and/or coughs
- Yes
List any frequent infections you might have:
Healing from surgeries/injuries: I seem to heal
- well
- not well
Detoxification
Frequency of bowel movements
- daily
- several a day
- every few days
- weekly or less
Are you doing, have you done or are you interested in any type of detoxification? (diet, colon, liver, gallbladder, etc)? Please describe:
I know I have had known significant exposure to:
- toxic chemicals/materials (ie: asbestos, paints, solvents, pesticides) -CURRENT
- toxic chemicals/materials (ie: asbestos, paints, solvents, pesticides) PAST
- regular use of brand name household cleaning products
- daily or weekly use of name brand personal/body care products and cosmetics
- synthetic clothing, carpets and/or furniture
- high tension power lines (live or work near them)
- high volume cell phone usage WITHOUT HEADSET
- high volume cell phone usage WITH WIRED HEADSET (not bluetooth)
- high volume cell phone usage WITH BLUETOOTH HEADSET
- high volume of computer usage with frequent exposure to WiFi
- unfiltered water for drinking/cooking
- unfiltered water for showering/bathing
Other toxin exposure
Have you ever smoked tobacco?
- Yes
- No
Do you still smoke?
- Yes
- No
Number of packs smoked per day
Number of years smoking
Date I quit
Sleep
Number of hours of sleep averaged nightly
Typical Time you go to sleep
Typical waking time
Rate the quality of your sleep
- Great
- Good
- Fair
- Poor
I wake up feeling
- Tired
- Anxious
- Only OK
- Refreshed
I remember dreams:
- Nightly
- Regularly
- Occasionally
- Rarely
- Never
Describe any sleep difficulties you have: (falling asleep, staying asleep etc)
Stress
Overall stress levels:
- Extremely high
- High
- Moderate
- Minimal
What do you consider your 5 top stressors (ie: financial, marital, job, cancer, other health issues, children, parents, other relationship) List in order of greatest to least.
1.
2.
3.
4.
5.
Have you worked with a mental health professional for depression, anxiety, loss or something else? If so will you share a little about this?
Physical and emotional signs/symptoms/behaviors of stress that you recognize for/in yourself
Stress reduction practices if any. Please include frequency and effectiveness
Emotional traumas (past and current and including significant losses) List known major emotional traumas and identify if past/current (p/c) resolved/unresolved (r/u)
1.
1. Past/Current?
- Past
- Current
1. Resolved/Unresolved?
- Resolved
- Unresolved
1. Degree of impact (1-10)
2.
2. Past/Current?
- Past
- Current
2. Resolved/Unresolved?
- Resolved
- Unresolved
2. Degree of impact (1-10)
3.
3. Past/Current?
- Past
- Current
3. Resolved/Unresolved?
- Resolved
- Unresolved
3. Degree of impact (1-10)
4.
4. Past/Current?
- Past
- Current
4. Resolved/Unresolved?
- Resolved
- Unresolved
4. Degree of impact (1-10)
Career
Currently I am
- Working
- Not working
I would like to be working
- Yes
- No
If working, please rate the following from 1-10 with 10 being high degree and 1 being minimal
I'm doing the work I love
Degree of fulfillment from work
Degree of stress and drain from work
Importance of work at this time
Positive impact of working/not working now
Negative impact of working/not working now
What, if anything, needs to change work-wise to better support you on your journey?
Authentic Expression and Life Purpose: Please rate 1-10 with 10 meaning very strongly so
Feeling seen and honored for who you really are by your partner
Feeling seen and honored for who you really are by your family
Feeling seen and honored for who you really are by your community
Engaging in many activities that really fill you
Amount and/or degree of withheld dreams/desires
Living your life purpose (whatever that means to you)
Self esteem: Please rate 1-10 with 1 being barely and 10 being very strongly so
Feel good about who you are
Love yourself
Setting appropriate boundaries between giving and receiving
Know how to ask for and receive help
feel worthy about who you are – right now
degree of guilt/shame
degree of withholding forgiveness of the self
Relationships: Please rate the following from 1-10 with 10 being strong agreement
my primary relationships are fulfilling
spouse or significant other is supportive
if no spouse or significant other, I have a desire for one
friends and co-workers support and love me
overall family support is very present
my children are a great source of support
my children are a major area of concern and stress
I have excellent care-givers in place
Overall, I feel guilty right now in my relationships
I feel seen, heard, supported and respected by my key healthcare providers
I have great support from a coach or therapist
History of abuse: childhood
History of abuse: past adulthood
History of abuse: current adulthood
I know I am harboring past resentments/forgiveness issues
I know I am harboring current resentments/forgiveness issues
Spirituality: Rate the following from 1-10 with 10 meaning you strongly agree
I feel a strong spiritual (or God) connection
I experience myself as supported or guided by a loving force
I experience guilt, anger, and/or unworthiness with regards to God or the Divine
I engage in spiritual practices
I have no interest in spiritual practices or support
Identify your strengths related to spirituality or religion and, if willing, identify your religious affiliation
List any spiritually related fears
List any spiritual goals you might have
Related specifically to your cancer challenge, please rate from 0-10 (with 10 being the strongest) your degree of:
Fear
Hope
Hopelessness
Support
Energy Level
Appetite
Aloneness
Concern for loved ones
effective and authentic communication with loved ones and caregivers
satisfaction with cancer treatment chosen
satisfaction with oncologist/primary physician
satisfaction with results of treatment
progression or return of cancer (or concern of)
Pain
ability to carry out desired activities
HealtheCare/Self-care: Rate on a scale of 1-10 with 10 being very well
overall, I am taking good care of myself
my overall level of health
I ask for help & allow myself to receive it
doing all I know to do for myself
connection & support from my healthcare team
taking care of others at my own expense
Advocate/Support Team: Rate on a scale of 1-10 your level of agreement (0 meaning no agreement and 10 full agreement)
I have a designated advocate who is aligned with my desires and values and can be present at most of my appointments and possibly scheduled treatments
I have a group of caregivers or people to support me in meeting my needs to do/receive/accomplish the care, activities and outcomes I seek
My top 5 reasons for living or staying alive are:
1.
2.
3.
4.
5.
Anything else you’d like to share:

Confidential New Client Intake Form

Confidential New Client Intake Form

About my Cancer

I eat or drink: (Rate the following on a 0­‐10 scale where 0 is never and 10 is always)

Servings per Week

I take or use the following: (D=daily S=several times a week O=occasionally N=never)

Dentistry

Immune System

Detoxification

Sleep

Stress

What do you consider your 5 top stressors (ie: financial, marital, job, cancer, other health issues, children, parents, other relationship) List in order of greatest to least.

Emotional traumas (past and current and including significant losses) List known major emotional traumas and identify if past/current (p/c) resolved/unresolved (r/u)

Career

If working, please rate the following from 1-10 with 10 being high degree and 1 being minimal

Authentic Expression and Life Purpose: Please rate 1-10 with 10 meaning very strongly so

Self esteem: Please rate 1-10 with 1 being barely and 10 being very strongly so

Relationships: Please rate the following from 1-10 with 10 being strong agreement

Spirituality: Rate the following from 1-10 with 10 meaning you strongly agree

Related specifically to your cancer challenge, please rate from 0-10 (with 10 being the strongest) your degree of:

HealtheCare/Self-care: Rate on a scale of 1-10 with 10 being very well

Advocate/Support Team: Rate on a scale of 1-10 your level of agreement (0 meaning no agreement and 10 full agreement)

My top 5 reasons for living or staying alive are:

I eat or drink: (Rate the following on a 0‐10 scale where 0 is never and 10 is always)