Registry form | Reliable Cancer Therapies

agreement:

I agree to allow RCT to contact the conventional and non-conventional treatment providers listed below.

Definitions

Conventional therapies

Therapies that have been approved by regulatory authorities and are now used in mainstream healthcare, also often called traditional or classical therapies.

Non-conventional therapies

All therapies that are not (yet) approved by regulatory authorities such as CAM (complementary and alternative medicines) and experimental or investigational drugs.

* = compulsory field

General information

1. How did you find out about Reliable Cancer Therapies?:

Patient association

Alternative practitioner

Medical doctor

Cancer Centre

Newspaper/magazine

Family/acquaintance

Internet

Other

2. Information about patient

Gender:

Male

Female

First name*, middle name: *

Last name:

Address:

City:

Postal code:

Country: *

Tel. home:

Tel. mobile:

E-mail: *

Date of birth: *

3. Information about sender (only if sender is not the patient)

First name*, middle name:

Last name:

Address:

City:

Postal code:

Country: *:

Tel. home:

Tel. mobile:

E-mail: *:

4. The sender of this form is:

Patient

Medical Doctor

Next of kin

Non-conventional treatment provider

Other

5. Which of these describe(s) your present situation?:

I work full time

I work part time

I am retired or early retired

I am unemployed

I am on sick leave

I am disabled

I am a home maker

I am a student

I am under 18 years

Other

6. What is your highest level of education?:

Less than 7 years of primary school

7 years (primary school)

Junior high school

High school 1-2 years

High school 3-4 years

College / university 4 years or less

College / university more than 4 years

Other

Disease history

7a. Who diagnosed your primary cancer for the first time?:

Medical doctor

Therapist

7b.Have you been diagnosed by another doctor (second opinion)?:

Yes

7c.If 'yes', the second opinion was performed by:

Medical doctor

Therapist

8. What is your diagnosis? And, if applicable, was there a difference between the first and the other diagnosis?:

9. Year and month of primary cancer diagnosis::

10. What is your current state of health?:

Conventional medical treatment

11. Have you received conventional medical treatment?:

Yes

No (if No, go to question 18)

12a. If yes, what kind of conventional medical treatment have you received?:

Chemotherapy

Surgery

Radiation

Other**

**Other: including physiotherapy, dietary advice, prescription drugs, etc.

12b. Please describe your conventional treatment in detail::

13. When did you start conventional medical treatment?:

14a. Have you completed your conventional medical treatment?:

Yes

14b. If 'yes', when did you complete your conventional treatment?:

15a. Have you experienced any positive effects of the conventional medicine?:

Yes

Do not know

15b. If 'yes',what positive effects? If 'do not know', please explain?:

16a. Have you experienced any negative effects of the conventional medicine?:

Yes

Do not know

16b. If 'yes',what negative effects? If 'do not know', please explain?:

17. Contact information for doctors/hospitals (incl. primary doctor).

Could you please supply us with information on the medical doctor/hospitals that have treated you for your disease. Use item 33 if not enough space.

Name of medical doctor/hospital:

Address:

City:

Postal code:

Country:

Telephone:

Date of first contact:

Name of medical doctor/hospital:

Address:

City:

Postal code:

Telephone:

Country:

Date of first contact:

Name of medical doctor/hospital:

Address:

City:

Postal code:

Telephone:

Country:

Date of first contact:

Non-conventional treatment

18a. Have you received non-conventional treatments in connection with your cancer diagnosis?:

Yes

No (if No, go to question 24)

18b. If 'yes', please describe your non-conventional treatment in detail::

19. When did you start non-conventional treatment?:

20a. Have you completed the non-conventional treatment?:

Yes

20b.If 'yes', when did you complete your non-conventional treatment?:

21a. Have you experienced any positive effects of the non-conventional treatment?:

Yes

Do not know

21b. If 'yes', what positive effects? If 'do not know', please explain?:

22a. Have you experienced any negative effects of the non-conventional medicine?:

Yes

Do not know

22b. If 'yes', what negative effects? If 'do not know', please explain?:

23. Contact information for treatment providers

Could you please supply us with information on the non-conventional treatment providers that have treated you for your disease. Use item 33 if not enough space.

Name of treatment provider:

Types of treatment:

Address:

City:

Postal code:

Country:

Telephone:

Date of first contact:

Name of treatment provider:

Types of treatment:

Address:

City:

Postal code:

Country:

Telephone:

Date of first contact:

Name of treatment provider:

Types of treatment:

Address:

City:

Postal code:

Country:

Telephone:

Date of first contact:

Your own information, experience and self help methods

24a. Were you undergoing any conventional or non-conventional treatments before you received the cancer diagnosis which you are registering?:

Yes

24b. If 'yes', describe the treatment or medication::

25.Did you experience any early symptoms before you received the cancer diagnosis (e.g. change in skin appearance or certain pains)? Please describe.:

26a. Have you noticed any changes in your general attitudes and feelings since you were diagnosed with cancer?:

Yes

26b. If 'yes', describe these changes::

27.Have you been able to talk easily about your cancer diagnosis with family and close friends?:

Yes

28a. Did you decide to make any changes yourself in any of the following? Mark as many as appropriate::

Diet/nutrition

Use of herbal or other medication

Excercise/Sport/Physical training

Mental attitude

Emotional expression

Life style (routines, sleep, habits, hobbies,...)

Work

Relationship

Other

28b. Describe these changes::

28c. What motivated you to make these changes?:

29. What do you feel has helped you most since the diagnosis, during the course of the treatment and since then in terms of cure, emotional support and good advice? Please describe.:

30. What, in your opinion, might be the cause of your cancer? Mark as many as appropriate.:

Genetic

Environmental factors (air,water,chemicals)

Own contribution

Life style

Stress

Smoking/Drugs/Alcohol

Exercise regime

Diet

Sleep pattern

Relationship

Work

Other

31. Would you like to make any further comments on the causes of your cancer?:

32a. What are your feelings/thoughts about conventional cancer treatments? Describe.:

32b. What are your feelings/thoughts about non-conventional cancer treatments? Describe.:

33. Additional information:In this space, please write any additional information about your disease, the treatment, the hospital or any other thing that you think might be relevant.:

Thank you very much for your contribution!