Patient Intake & Care Plan Questionnaire

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General Information

Patient Full Name *

Email *

Phone No# *

Case ID *

Patient Date of Birth *

Country *

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Please chose one

Intake
Follow up

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Optional

Primary Local Oncologist

Local Medical Oncologist *

Surgeon *

Radiation Oncologist *

Other Providers *

Would you like us to have a trusted contact on file?

If there’s a family member, close friend, or someone you’d like us to reach out to on your behalf when needed, feel free to share their name below. If not, no worries at all—your privacy is always our priority. Without a listed contact, we can only communicate directly with you.

Full name

Phone

Relation

Full name

Phone

Relation

Full name

Phone

Relation

Type of Cancer *

Other (Please Type)

Disease *

Rate Your - Patient's Performance *

Fully active, able to carry on all pre-disease performance without restriction.
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work.
Ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours.
Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours
Completely disabled; cannot carry on any selfcare; totally confined to bed or chair

Metastatic Disease *

Yes
No
I don't know

As reported by your cancer care provider

What are your concerns about your disease? *

Diagnosis Uncertainty
Question Regarding the Accuracy of Disease Stage
Treatment Options
Side Effects of Treatment
Pain
Prognosis
Recurrence
Diet and Nutrition
Mental Health (Mood and Being Hopeless)
Financial Burden
Impact on Family and Care Givers
Bowel Habits
Genetic nature of the disease and concern about other family members
Care Coordination and feeling lost in navigating the cancer
Fertility and Sexual Health
Body Image (Anxiety about physical changes, such as hair loss, scars, or ect)
Work and Career
Questions about the safety and efficacy of complementary and alternative therapies
Clinical Trials
Legacy and Life Goals

(Check all that apply)

Other

Description: please provide a brief explanation of any other matters that are your concern.

Have you had any unexpected emergencies or doctor visits since our last session, or over the past month if it has been more than one month since our last session? *

What are the importance dates in your life in the next month ? (Complete this at least once a month)

Cancer Related

Chemo

Date

Immuno

Date

Radio

Date

Surgery

Date

Important Doctor Visit

Date

Imaging such as CT, MRI or PET scans

Date

Other

Single Line Text

Please describe (Optional)

Date

Other

Description: If you select “Others,” please provide a brief explanation of any cancer-related matters that are important to you in the next month.

Personal

Birthday

Date

Family events

Date

Wedding

Date

Graduation

Date

Planned trip

Date

Other

Date

Other

Description: If you select “Others,” please provide a brief explanation of any personal matters that are important to you in the next month.

Goals and Hopes to Achieve in the Next 6 Months
(These are common hopes for cancer patients, but they don’t have to be yours. Please take your time to think carefully and list all of your hopes. This is the most important question on this form, as our goal is to help you and your loved ones achieve them)
(Only at the start of Journey with us and every 6 months)

Personal Goals *

Improve mental health through counseling, mindfulness, or support groups
Achieve fitness goals (e.g., walking a certain distance)
Better self-care such as better nutrition, sleep, and stress management.
Achieve personal milestones, such as finishing a project or starting a new hobby.
Build resilience and a positive outlook for the future
Attend a wedding, Graduation or going for trip always wanted to go
Get back to normal life.
Pursue hobbies or activities that bring joy and relaxation
I don't have goal at this point of my life

Other

(Please list) & List a few relevant hobbies or activities that bring joy and relaxation.

Cancer Related *

Complete treatment without significant side effects.
Achieve remission or reduce tumor size.
Manage or minimize symptoms such as pain.
Participate in a clinical trial if applicable.
Enhance overall physical strength and stamina

Other

Description: Please provide details about your current or planned cancer treatment, including any specific preferences or considerations.

Family Goals *

Spend quality time with family and loved ones , Please define quality time.
Create meaningful memories, such as vacations or special events.
Have open, honest conversations with family about feelings, fears, and hopes.
Ensure dependents or children feel supported and reassured.
Strengthen family bonds by engaging in shared activities.
Prepare or revise plans for the future, such as wills or financial arrangements
Celebrate milestones, such as birthdays , anniversaries, or graduation.
I don't have goal at this point of my life

Other

Description: Please specify any additional personal or treatment-related goals you have for your cancer care journey.

Preferred Communication Method *

WhatsApp
Email
Phone Call

Patient's the Personal

I agree to the Term&Conditions.

I acknowledgment the Patient Data Residency.

Care Navigator Assistance

To ensure we provide the best support, please mention the name of the Care Navigator who assisted you in filling out this form. Your feedback helps us improve our service. Thank you! 😊