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Inquiry form for medical treatment in Japan
翻譯搜尋結果
Everyone's symptoms are different, especially the treatments used are different and the side effects are also different. [Medical Supporter] consultation, hoping to relieve the anxiety of the patient's family members. If you are still unclear about immune cell therapy, please fill out this form and get in touch with a medical assistant. We will contact you in the shortest possible time. Note: Your information will be stored in our database and will only be used by medical assistants and medical institutions.
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Name
*
Your answer
Patient Name
*
Pass if you are the patient
Your answer
The relationship with patient
Pass if you are the patient
Your answer
Sexual
*
male
Female
Prefer not to say
The patient birthday
*
MM
/
DD
/
YYYY
Please enter the diagnosed symptoms (Primary)
Your answer
Is the tumor has metastasized, if so, please let us know the metastatic organ.
Your answer
When are the patient diagnosed?
Your answer
Which hospital is the patient get treatment?
Your answer
Which stage?
Stage Ⅰ
Stage Ⅱ
Stage Ⅲ
Stage Ⅳ
Unknown
Clear selection
What kind of treatment is be made?
If the patient takes chemotherapy, please briefly describe which drugs were used and when. If you have surgery, please fill in the date of surgery and we can grasp the situation! Thank You.
Your answer
Does the patient have any of the following infectious diseases?
Hepatitis A
Hepatitis B
Hepatitis C
HIV
Syphilis
HTLV-1
None
Clear selection
Do you have any allergies to medicines or food?
None
Medicines
Food
Clear selection
Do you have experience in blood transfusion and organ transplantation?
Blood
Organ transplantation
None
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Does the patient have any chronic diseases in the past?
Such as diabetes, high blood pressure, etc. If not, please leave blank, thank you!
Your answer
Please enter the question you want to ask, please describe briefly.
Your answer
How is the patient ECOG performance Status
PS 0 (Fully active, able to carry on all pre-disease performance without restriction)
PS 1 (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)
PS 2 (Ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours)
PS 3 (Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours)
PS 4 (Completely disabled; cannot carry on any selfcare; totally confined to bed or chair)
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