TELL US ABOUT YOUR MEDICAL RECORD Name Date of birth Email Gender FemaleMale Phone What is your diagnosis? In case of cancer, do you have any metastases? YesNo where? Date when the diagnosis was made How many and which treatments have you received? Date of last treatment received Do you drink alcoholic beverages? YesNo how often? Do you smoke? YesNo how often? Do you take any medications? YesNo which medications? Do you have any pain? YesNo Additional information you would like to add
