Patient Name
E-Mail:
Age	Sex
Patient Address
Physician's Name
Initial Diagnosis:
Date of Diagnosis
Progression of the disease
Current Treatment (describe - provide start date, type, dose and response)
Other Medical Conditions
Please list all medications you are currently taking (Medication, dosage and condition precribed for)
PERFORMANCE STATUS (Please Check just one of them - 10 thru 100)
Able to carry on normal activity; no special care is needed
100 Normal; no complaints, no evidence of disease
90 Able to carry on normal activity, minor signs or symptoms of disease
80 Normal activity with effort; some signs or symptoms of disease
Unable to work; able to live at home; cares for most personal needs; a varying amount of assistance is needed
70 Cares for self, unable to carry on normal activity or to do active work
60 Requires occasional assistance but is able to care for most of his needs
50 Requires considerable assistance and frequent medical care
Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly
40 Disabled; requires special care and assistance
30 Severely disabled; hospitalization is indicated, although death is not imminent
20 Very sick; hospitalization is necessary, active supportive treatment is needed
10 Moribund, fatal processes rapidly progress
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Medical Records

Request a copy of your medical record file from your attending Physician’s Medical Office:

Records can be accepted in Spanish or English. When medical record translation presents a problem contact Cathy Vega for information on how to comply.

The following are examples of the medical records that would assist with our evaluation and need to be as complete possible.
Provide copies of Report Summaries only:(No Film)

Biopsy / Pathology / Histological Report:

Reports that confirms the initial diagnosis.

Imaging and Lab Results:

CAT, PET, or MRI Scan results. (Chest, Abdomen and pelvis, Bone, Brain etc.)

Blood Work specific to diagnosis results (CBC, CBC with differential, tumor markers, hormones, etc.)

Surgery reports with date, Pathology reports and Scan reports that demonstrate results.

Physicians Reports:

Physician commentary with brief personal medical history, oncologic and any other non-oncologic disease updates and treatments

Forward copies of your Medical Records for medical staff review - Via:

A. Via Email: (Scan Medical Records, Size of files must be manageable, PDF or Tiff)

Email Address: sioffice@saludintegral.hn

B. Via Express Mail: (Ship DHL, Federal Express etc.)

Express Mail Address:

Salud Integral, S. A. de C. V.
Attn: Cathy Vega
Colonia Lomas del Guijarro
Edificio Plaza Azul, 6to. Nivel
Tegucigalpa, Honduras, C.A.
Phone: 504-325-3941

C. Via Fax: (Fax if record file is not to large)