Patient Questionaire

Are You a Candidate for Our Treatment?

To be considered for the Targeted Osmotic Lysis (TOL) trial, please complete the comprehensive HIPAA compliant patient intake questionnaire in its entirety. Provide accurate and detailed information to the best of your knowledge, as this will help our medical team determine your eligibility for the treatment. If you have any questions or need assistance while completing the questionnaire, please do not hesitate to contact us.

Upon completion, our clinical liaisons will reach out to you to arrange an in depth telehealth call with our medical team.

Personal Information

First name

Last name

Age

Phone Number

Type of Cancer

Give us a brief description of your type of cancer.

Type

Stage

Date of Diagnosis

Summary of Cancer

Summary of your cancer in your own words. Please include anything that may be helpful to your healthcare providers and include information about any treatments or pertinent procedures you have undergone such as surgery, biopsies, imaging, etc. Also include where such procedures or treatments have been performed:

Please check all types of previous cancer treatments you have received:

Please indicate any diagnostic imaging studies you have undergone as part of your cancer evaluation. Check all that apply:

Type of Imaging

Date of Last Imaging

Please describe any symptoms or side effects you are experiencing related to your cancer or previous treatments:

Activity Status

Do you have the physical capacity for air travel

Allergies:

Is there any additional information you would like to provide about your medical history, treatment preferences, or concerns?

Once you have completed the questionnaire, our team will review your responses and reach out to you to discuss your eligibility for our treatment program. We understand that navigating metastatic cancer can be challenging, and we are here to provide support and guidance every step of the way.

We look forward to helping you through your cancer journey.