Call us: 1-619-468-9209
to discuss your treatment options
New Patient Form
Prospective new patients for Hope 4 Cancer should complete the following information. A physician will review this and arrange for a private consultation. Please complete all of the information found on this form
Your Health is Our Top Priority
Name (required)      
Telephone (required)    
Email (required):    
City    
State    
Occupation  
Age  
Sex Male Female
Status Single Married Divorced Widow(er)
List Your Symptoms / Complaints Treatments Received
What is your Diagnosis?:
When was your Diagnosis made?:

Has there been any recent changes in:
Your appetite or eating habits Yes No
Your bowel movements or stools Yes No
Habits
Exercise Adequate Yes No
How do you Exercise?
Sleep well? Yes No
Average 8 hours? Yes No
Bowels move regularly? Yes No
Diet well balanced? Yes No
Alcoholic Beverages Never Rarely Moderate Daily
Tobacco: packs per day Cigarettes: packs per day
Cigars Pipe Chewing Tobacco Snuff
Drugs:
Laxatives Never Occasionally Frequently Daily
Vitamins: Never Occasionally Frequently Daily
Sedatives: Never Occasionally Frequently Daily
Tranquillizers: Never Occasionally Frequently Daily
Sleeping pills, etc: Never Occasionally Frequently Daily
Aspirin, etc.: Never Occasionally Frequently Daily
Cortisone, ACTH: Never Occasionally Frequently Daily
Thyroid: Never Yes in the Past Now
Appetite suppressants: Never Occasionally Frequently Daily
Have you ever been treated for drug habits Yes No
Have you ever taken insulin, tablets for diabetes Yes No
Hormone shots or tablets Yes No
Work: hrs/day indoors hrs/day outdoors
 
Women Only
Menstrual History
Age of onset
Regular Yes No
Cycle days(from start to start)
Usual duration days
Heavy Medium Light
Pains or cramps Yes No
Date of last period
How many children born alive
How many premature
How many Cesarean Sections
How many miscarriages
Any complications with any pregnancy Yes No
 

 


USA Mailing Address
482 W. San Ysidro Blvd. #1589
San Ysidro CA 92173
USA
Tel. (619) 468-9209
Fax. (619) 923-5000
Mexico Mailing Address
Avenida del Pacifico #650
Playas de Tijuana, B.C.
Mexico
Tel. 011-52 (664) 680-6654
More Information
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Hope4Cancer
Patient Guide
Download it here 		New Patient
Entry Form
Download it here 		Introductory Video
Featuring Dr. Tony
Watch it now