Bharatiya Sanskriti Darshan Trust’s

INTEGRATED CANCER TREATMENT & RESEARCH CENTRE

AYURVED HOSPITAL & RESEARCH CENTRE
Vishwashantidham, Kesnand Road, Wagholi, Pune – 412207

Questionnaire To be Answered by the Patient

1. Full Name– Mahesh Rajbhar

2. Age– 52 Sex- Male Height - 5.8 feet

3. Birthdate - 04/06/1967 Birthtime- 11.30 A.M Birth

place– Mumbai

4. Marital status – Married ✓ / Unmarried / Divorcee / Widow – Widower (Tick whichever

is appropriate)

5. Permanent Address– Kanji Chawl match factory lane, HPK road Kurla west Mumbai 400070

6. Temporary Address–

7. Telephone no.–

8. Mobileno.– 9769287092 Whatsapp no.- 9594441048

9. Email id– ajayrajbhar10851277@gmail.com

10. Skype id–

11. Reference – Newspaper / Website / Patient at ICTRC / Relatives / Other Doctors✓

– Providedetails

12. Educational Qualification- SSC

Integrated Cancer Treatment And Research Center, Wagholi, Pune, M.S., India
Email – ictrcpune@gmail.com
Website – www.ayurved-for-cancer.org
Page 1
Job profile – Self owned Business / Job / House wife / Student / Retirement Fill the
following details - (present job and previousjob)

Sr. Occupation Nature Duty hours Total Duration

No sedentary/ shift duties/
travelling / trading /
professional/ intellectual
1 Service Food product supplier 8 hours

13. Details about History of Past ill ness (other than cancer)– Nothing

a. Details of your birth delivery – Normal ✓/ Caesarean / Forceps /At home / At Hospital
Any complications–

b. Previous Surgery details ifany–

Sr. No Name of Surgery Reason for surgery Doctor / Hospital Name

1 CLW Finger Cut Dr. Shetty Hospital ( Marol naka)

c. Any trauma / accidents/fractures–

Sr. Type of Time of Treatment taken Any Deformity

No trauma / occurrence remained
accident / Yes/No
fractures Type of deformity
d. Past Diseases–

Sr. No Name of Disease Time of occurrence Treatment taken

14.Details about any present disease (like hypertension, diabetes, thyroid problem, etc other
than cancer) and details of medicines for it–

Sr. No Name of Present Time of occurrence Ongoing Treatment ( Mention

Disease the names of medicines with
dose )

15. Family History–

Relation Age of relative at Cancer Other diseases

time of diagnosis Same site Other site (other than
cancer)
Maternal
side

Paternal Father 55 (in 1995) Diabetes

side

Same
generation
( sister /
brother)
Next
generation
(children)
16. Addictions–

Sr. Addiction Quantity Frequency Duration

No
1 Alcohol 2 Pack Twice in a month

2 Smoking

3 Narcotics

4 Others –

17. General information-

Sr. No Present Past

1 Appetite Normal Normal

2 Digestion Normal Normal

3 Stools / bowel habits Normal Normal

4 Urine habits Normal Normal

5 Sleep Normal Normal

6 Tendency of worms Nothing --

7 Weight 59 63

8 B.P -- --
 CANCER RELATED HISTORY

18. Details about CANCER / Metastasis / Recurrence–

Details about Primary Cancer

Site Time of occurrence Treatment – previous and ongoing ( in short)

Left segment 20/02/2020 20 Feb 2020 - 27 Feb 2020
mandibulectomy + left
SND + Fibula

Details about Recurrence of cancer ( same site), if present

Site Time of occurrence Treatment – previous and ongoing ( in short)

Left segment 19/09/2020
mandibulactory + left
SND + FFOCF

Details about Metastasis to other site, if present

Site Time of occurrence Treatment – previous and ongoing ( in short)

19. CANCERrelated history in the form of signs andsymptoms-

Sr. No Signs & Symptoms / Complaints Severity of symptoms

with specifications *
1 During diagnosis

2 After cancer
treatment, whether
signs subsided or
increased

3 During metastasis, if
present

4 During recurrence, if
present

5 Present complaints

(* for example – if patient suffers pain in abdomen, specify whether it is throbbing /

pricking / pinching pain and when it aggravates.)
20. Details about CANCERTreatment–

a. Surgery details -

Sr. Surgery details Date Surgeon name Hospital name

No.
1 Left segment mandibulectomy 20/02/2020 Dr. Rakesh Katna Vedant hospital, Thane
+ left SND + Fibula

b. Chemotherapy details-

Set Cycle Date Chemotherapy Side - effects Name of Oncologist

No. No. medicines with / Hospital
dose
c. Radiotherapy details-

Site Dose Fractions Days Started Taken Side - effects Nameof

in cGy from till Radiologist /
(Date) (Date) Hospital
d. Oral chemotherapy / Hormonal treatment details-

Oral Chemotherapy

Medicine Started Taken Side - effects Name of Oncologist /

name with from till Hospital
dose (Date) (Date)

Hormonal Treatment

Medicine Started Taken Side - effects Name of Oncologist /

name with from till Hospital
dose (Date) (Date)
Neukine 300 UG S/C After 2 days of
Every
Chemotherapy

21.Any current supportive treatment other than Allopathy for Cancer- (Ayurvedic /
Homeopathic/Naturopathy/Chinesemedicines/Anyotherpathy),mentiondetails-

Name of Started from(Date) Medicine name Name of Doctor

Pathy Taken till (Date) /
Ongoing
22. Emotional status–

1. Nature – Calm ✓ / Angry / Aggressive /Pessimist / Optimist /Fearful ✓

2. Mental stress if any - Physical / Financial ✓ / Mental / Professional ✓ /

Social ✓ / Familyrelated ✓

3. Duration of stress- from last 2-3 years

4. Change in behavior after diagnosis of Cancer– Became Quite

23. Daily water intake–

a. Doyoudrinkwateronlywhenyouarethirstyorwhetheryouarehabituatedtodrinkwater– only when thirsty

b. Type of water – Corporation water/ Borewell water/ Well water/ Tanker water/Aquaguard ✓ /Cold
water/ Boiled water/ Springwater

Sr. Time of water intake Quantity (in glass) Seasonal variation

No
1 Early morning, empty 1 glass
Stomach

2 Before meals

3 In between meals

4 After meals 1 glass

5 Before going to sleep at night 1 glass

6 During night time 500 mll

7 Other specific times

8 Total water intake ( per day) 2- 2.5 liter

24. Present Diet-

Time Food items Quantity Anyspecial

information
Early morning drinks / water
9 A.M Coconut water 300 Ml

Breakfast
10.30 A.M Milk and roti 2 roti

Lunch
12 Noon Butter milkt 300 ml

2 P.M Beetroot and Carrot juice 300 ml

3.30 P.M Daal khichdi 500 ml

Evening snacks
6 P.M Tea and Biscuits 6-7 biscuit

7.30 P.M Boiled eggs 2

Dinner
9.30 P.M Daal khichdi 500 ml

11 P.M Milk with protein powder 150 ml

In between food stuffs – If any

Drinks – like Pepsi, Coca cola, Coffee, Milk

Specific food items – like Chocolate, Ice -cream, Yogurt, Fruit Yogurt, Milk shakes,
Chips, Chinese noodles, Pizza
 For Female patients only

MENSTRUAL HISTORY

Sr.
No
1 Onset

2 Menstrual flow – Regular / Irregular

3 Flow - Scanty / Heavy / Painful /

Absence of menstruation / Presence of
clots

4 Specific odour

5 Symptoms before or during Menstrual

cycle – Stomach pain, Backache, Leg
pain, etc

6 Duration of menstrual cycle --- days/

7 Menopause age

Pre-menopausal symptoms, if any

Treatment if taken

8 Leucorrhoea (White discharge) Yes / No

Color of discharge – Yellow / greenish /

white

Consistency – watery / normal / sticky

Whether accompanied with itching or

burning sensation around vaginal area

9 Age during marriage

Number of marriages

10 Any other details

 OBSTETRICS HISTORY

Sr.
No
1 Age during first pregnancy

2 Age when gave birth to first child

3 Number of child births with gender

4 Normal delivery / Caesarean section /

Forcep delivery

5 Pre- mature delivery / Full term delivery

6 Miscarriages / Abortions

7 Treatment if taken for pregnancy

8 Any diseases occurred during pregnancy

9 Use of contraceptives with duration ,

specify
Pills / Copper T / Tubectomy / Cu T etc.

10 Weaning done – Yes / No

11 Duration of Weaning

12 Milk secretion – scanty / excess /

proportionate

13 Any other details