Case Evaluation

Practice
Dr. med. Gerhard Siebenhüner
Vilbeler Landstrasse 45 B
60388 Frankfurt
Phone +49 (0) 69 63 20 00
Fax +49 (0) 69 63 70 77

Our Surgery Hours
Mon - Fri from 8 a.m. to 6 p.m.

Basic information

Gender (patient) *
First name (patient) *
Name (patient) *
Age (patient)
Town (patient) *
Country (patient) *

eMail-Address (patient) *
Phone
Fax

What kind of original cancer was diagnosed?

Date of first recognized indiations?

If another person is writing for patient - Writer's name:

Gender
First name
Name

Therapies carried out so far:

year: 1st: result: year: 2st: result: year: 3st: result: year: 4st: result: year: 5st: result: year: 6st: result:

Information regarding your current health situation:

Known metastases existent? If yes: Where?

Current situation?

Patient's current condition? (please select one)

100: Normal

90: Able to carry on normal activity; minor symptoms of disease

80: Normal activity with effort; some symptoms of disease

70: Cares for self; unable to carry on normal activity or active work

60: Requires occasional assistance but is able to care for needs

50: Requires considerable assistance and frequent medical care

40: Disabled; requires special care and assistance

30: Severely disabled; hospitalization is indicated

20: Very sick; hospitalization necessary; active treatment necessary

10: Moribund; fatal processes progressing rapidly

Other current illnesses:

Other patient information:

Patient needs special care...

Patient could travel to Frankfurt am Main:

Yes No

Patient would come...

alonenot alone

Accomodation wanted...

Patient would like to have more information regarding the ...

chances of treatment by Gerhard Siebenhüner
estimated duration for treatment in Frankfurt
estimated duration for repeat treatment
estimated costs for treatment
results to be expected

Personal communication to Gerhard Siebenhüner:

Security check *

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