Please fill out and return this Pre-consult Questionnaire. You can email your responses to ghildenbrand@earthlink.net or print it out and fax to 858-759-2502. After you return your questionnaire, please contact Gar Hildenbrand 858-759-2262.

Pre-consult Questionnaire

 Identification Data:

 Last Name:

 First Name:

 Address:

 Date of birth:

 Age:

 City/State:

 Sex:

 Race:

 Country:

 Marital status:

 Spouse:

 Phone:

 Place of birth:

 Religion:

 Fax:

 E-mail:

 Emergency Contact:

 Present Illness:

 Diagnosis:

 Histology:

 Date of original diagnosis: 

 Stage:

Treatment History: Please list the chronological history of the present illness (dates and the treatments including alternative therapies in addition to surgeries, chemotherapy, radiation).  Include important scan reports (those that diagnosed or showed growth or shrinkage of disease).

Dates

Events

Current treatment regimen: Please list current program including mainstream, complementary, alternative treatments (please include list of supplements).

Current Condition: Please mark an “X” in the box if you have any of the following, and give a brief explanation

Pain

Constipation

Jaundice

Anemia

Loss of appetite

Personal History: Mark an “X” in the box next to any of the following that you have now or have had in the past.

Coronary Heart Disease

Diabetes

Irritable Bowel

High Blood Pressure

Rheumatoid Arthritis

Crohn’s Disease

Diabetes

Autoimmune Disease

Depression

Stroke

Malaria

Anxiety

Other

Performance Status: Please mark with an “X” the statement which best describes your current physical status

Normal activity

Symptoms but ambulatory

In bed less than 50% of the time

In bed more than 50% of the time

Completely bedridden

Please take a few minutes to answer the following questions. Your answers will set the “baseline” for your quality of life measures upon your arrival in our program. Please answer all the questions, even if your answer is a quick “guess”.

PART ONE

Performance/Activity Status

KARNOFSKY PERFORMANCE STATUS SCALE

1. Please mark the following chart to indicate your percentage of performance.

Definition

X

%

Criteria

Able to carry on normal activity and to work. No special care is needed.

100

Normal; no complaints; no evidence of disease.

90

Able to carry on normal activity; minor signs or symptoms of disease.

80

Normal activity with effort; some signs or symptoms of disease.

Unable to work, Able to live at home, care for most personal needs. A varying amount of assistance is needed.

70

Cares for self. Unable to carry on normal activity or to do active work.

60

Requires considerable assistance, but is able to care for most of needs.

50

Requires considerable assistance and frequent medical care.

Unable to care for self. Requires equivalent of Institutional or hospital care. Disease may be progressing rapidly.

40

Disabled: requires special care and assistance.

30

Severely disabled; hospitalization is indicated although death not imminent.

20

Very sick; hospitalization necessary; active supportive treatment necessary.

10

Moribund; fatal processes progressing rapidly.

                                                               

2. Which of the following best describes your level of activity today? Mark the box with an “X”.

Normal activity

Symptoms but ambulatory

In bed less than 50% of the time

In bed more than 50% of the time

Completely bedridden

PART TWO

Place an “X” next to the closest answer to each question.

1. How in control of your health do you feel?

Totally

Reasonably

So-So

Not very

Not at all

2. How would you rate your physical health?

Excellent

Very good

Good

Fair

Poor

3. How much pain do you have?

None

Almost none

Some

Quite a lot

Too much to bear

4. How would you rate your mood?

Great

Pretty good

Fair

Not good

Terrible

5. How would you rate your confidence?

Completely Solid

Pretty good

So-So

Not good

Terrible

6. How much do you worry about your illness?

Not at all

Very little

Some

Quite a bit

It’s all I do

7. How much support do you get from your family?

Total

Quite a bit

Some

Not very much

None

PART THREE

Please mark an “X” on the scale below each question

Never                                                                                                      Continually

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

X

                                    (Sample)

                                       

1. Most people experience some feelings of depression at times. Rate how often you feel these feelings.

Never                                                                                                      Continually

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

 

2. How well are you coping with your everyday stress?

Not well                                                                                                     Very well

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

3. How much time do you spend thinking about your illness?

Continually                                                                                                      Never

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

4. Rate your ability to maintain your usual recreation or leisure activities.

Able                                                                                                              Unable

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7              

5. Has nausea affected your daily functioning?

Not at all                                                                                               A good deal

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

6. How well do you feel today?

Extremely poor                                                                                  Extremely well

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

7. Do you feel well enough to make a meal or do minor household repairs today?

Very able                                                                                                    Not able

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

8. Rate the degree to which your illness has imposed a hardship on those closest to you in the past two weeks.

No hardship                                                                           Tremendous hardship

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

9. Rate how often you feel discouraged about your life.

Always                                                                                                            Never

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

10. Rate your satisfaction with your work and your jobs around the house in the past month.

Very dissatisfied                                                                                 Very satisfied

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

11. How uncomfortable do you feel today?

Not at all                                                                                    Very uncomfortable

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

12. Rate how disruptive your illness has been to those closest to you in the last two weeks.

Not at all                                                                                                 Completely

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

13. How much is pain or discomfort interfering with your daily activities?

Completely                                                                                              None at all

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

14. Rate the degree to which your disease has posed a hardship on you, personally, in the past two weeks.

Tremendous hardship                                                                           No hardship

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7              

15. How much of your usual household tasks are you able to complete?

None                                                                                                              All of it

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

16. Rate how willing you were to see and spend time with those closest to you in the last two weeks?

Not at all                                                                                                Very Willing

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

17. How much nausea have you had in the last two weeks?

Constant                                                                                                          None

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7              

18. Rate the degree to which you are frightened of the future.

Completely terrified                                                                         Totally unafraid

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

19. Rate how willing you were to see and spend time with friends in the past two weeks.

Not willing                                                                                              Very willing

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

20. How much of your pain or discomfort over the past 2 weeks was related to your illness?

None of it                                                                                                      All of it

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7              

21. Rate your confidence in your prescribed course of treatment.

Complete confidence                                                                        No confidence

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

22. How well do you appear today?

Very well                                                                                                     Terrible

1   ------------  2   -----------   3  ------------   4  -----------    5  -----------    6  -----------   7             

PART FOUR

Write a little story, as if you were explaining the illness you are dealing with to a small child, and please feel free to write a happy ending. (This exercise is optional and may seem “silly” but is in fact a form of “qualitative research” — Please give it a try!) When you have completed the story, please send the completed questionnaire to ghildenbrand@earthlink.net.