Cancer Buddy Personal Profile Form - Cancer Healing Buddy

Please fill in the form with your personal details.

The more i know about you and your family, your living environment and your cancer, the better i can serve you as your Cancer Buddy.

Your information is strictly confidential and will not be shared with any 3rd Party.

Please submit the form once you have filled in your information.

Personal Information

First Name *Enter your first Name
Last Name *Enter Last Name (Surname)
Address *
Enter your AddressStreet AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Gender *
Choose genderMaleFemale
Date of birth dd/mm/year
Current Date *
Email *Enter your Best E-mail here
Phone - Free appointment Please provide me with a phone number that we can use if we go ahead with the FREE telephone call to discuss the Coaching Program. If you prefer Skype fill in the Skype Box below.
Skype - option
if you would prefer Skype to a telephone appointment, please fill in your skype address - no videos (cameras) will be used to utilise the bandwidth most effectively
Status *
Enter your current statusSingleMarriedDivorcedWidowed
Cancer Coaching Program Expectations *
Please select the things you would like to get from the Healing Program. If you have other requirements please add them in the Text box below - Additional Expectations.Establish a customized cancer healing programGet guidance on effective cancer diets (alkaline diet)Get guidance on what you May NOT eat if you want to have a chance to beat cancerGet guidance on what the best natural alternative treatment options are available for you to choose.Get guidance on what the best natural alternative therapy options are available for you to choose.Have a "Cancer Buddy" relationship to have a compassionate friend to share difficult times, who understands what you are going throughHave a "Cancer Buddy" to just chat when lonely or depressedShare both difficult and good experiencesAsk questions about cancer and your fearsFind out about the best books and equipment that you should considerFind out more about critical herbs, superfoods and natural supplements you should considerFind out why you should only eat organic vegetables and low sugar fruit.Find out why you should only eat organic vegetables and low sugar fruit.Understand why being Positive and Grateful are so importantUnderstand the Law of Attraction and why you should be using Affirmations as part of your Healing ProgramUnderstand how your sub-conscious mind can affect your healing processUnderstand the critical healing secret - The "heart and soul".OTHER - Anything else you want to include - use the text area below
Additional Expectations - please fill in
Please describe any additional expectations that you would like from this Coaching Program
Spouses Details
if you are engaged or married please provide your fiancee / spouses name, age, how long you have been engaged or married - and if she lives with you and is supporting you with respect to your cancer ?
Picture Up Load a picture of yourself
Children *
How many children do you have ?none123-45 - 6More than 6
Details of Children
Please list your Children's names and ages and if they live at home with you or not ?
Grand Children
How many Grand Children do you have ?none1-23-66
Lifestyle *
Choose the description that best best describes how you feel from day to day. You can choose multiplesI am a happy, positive and grateful personI am a negative personI am a angry and bitter personI complain a lotI criticize a lotI judge other people a lotI am a moody person
Heart and Soul *
Please choose the the description that best describes how you feel from your heart. you can choose multiple options.I am a compassionate personI am passionate about helping othersI like to serve people and dont expect anything in returnI am a loving personI love myself as i amI am a grateful personI respect othersI forgive easily and dont hold grudgesI am very honest with people and say what i feelI am a gentle person at heartI am not a jealous personI have a strong belief systemI know i WILL be healed from my Cancer !
Current Cancer Status *
Have you had cancer, or do you currently have cancer ?I had Cancer - but I am in remissionI currently have cancer
Cancer Diagnosis - *
Please describe how and when your cancer was diagnosed, what tests were used and the information on the type, stage, aggression, and prognosis of your cancer - if any
Cancer Type - stage *
Please describe the primary type of cancer and the stage as well as any secondary cancers caused from spreading (metastasis)
Cancer details *
When were you diagnosed with Cancer ?1 year ago2 year ago3 year ago4 year ago5 year agoMore than 5 year ago
Cancer treatment - Chemo *
Please list the following information: 1. Have you had Chemotherapy, or currently undergoing Chemotherapy ? 2. What type of Chemo ? 3. How many Chemo sessions have you had ? 4. What side effects have you had ? (main ones) 5. Do you think the Chemo is working ? 6. Are you going to continue with Chemo ?
Cancer treatment - Radiation
Please give details of any Radiation you have had and the dates and if you are still having radiation ?
Cancer treatment - Surgery
Please describe any surgery you had, what and when ?
Natural Alternative Treatment Assessment *
Please select the points that relate to your situation. describe if you have, or are currently using a natural / alternative Treatment. 1. Did you previously have either chemo, radiation or surgery before starting Alternative treatment ? 2. Please describe the alternative treatment 3. Please describe your current diet 4. Please describe the following lifestyle choices - Do you - smoke, eat / drink dairy products, eat red meat, eat any fast foods ? drink any soft drinks, drink any alcohol, have processed for more than 4 times a week, eat breakfast cereal, eat white bread, cakes or biscuits regularly. 5. Do you work full or part - time away from home ? 6. Please describe any hobby / or hobbies ? 7. Do you have regular cancer marker tests or scans, PSA etc ? 8. Are your cancer markers improving.I am using natural alternative treatmentI am using natural alternative therapiesI did have conventional treatment before starting natural alternative treatmentsI did have Chemo - but have finishedI am still having ChemoI did have radiationI am scheduled to have more radiationI did have surgeryI am scheduled to have surgery soonPlease give more details in the text area below
Alternative Cancer Treatment Description
Please describe what alternative treatment and therapy you have had.
Lifestyle Choices *
Please select the points that relate to your current lifestyle. You must select multiple points.I am on an alkaline cancer dietI do not smokeI have smoked before for 5 years or moreI drink alcohol moderatelyI drink a lot of alcoholI am on addictive drugsI eat and drink dairy productsI eat red meat at least twice a weekI eat processed foods at least 4 times a weekI eat breakfast cereal at least 4 times a weekI eat white bread and or cakes and or biscuits at least 4 times a weekI eat pasta and or Pizzas at least twice a weekI work full time away from homeI work part time away from homeI work at homeI have regular cancer tests (monthly)My tests are showing an improvement
Relaxation and Hobbies *
Please list any hobbies and or sport as well as what you do for relaxation
Stress and Trauma *
The two biggest causes of cancer are stress and trauma. Please can you describe 5 situations where yo were stressed for an extended period of time or when you went through traumatic experiences - Try to remember how old you were on each occasion and list the reasons and the outcomes.
Remission *
Are you in Remission ?YesNo
Remission
How long have you been in Remission ? Ignore if you are not in Remission.1 year2 years3 years4 years5 yearsmore than 5 yearsmore than 10 years
Wishes, Dreams and Asperations *
Describe your wishes, dreams and aspirations ?

Verification

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