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In order to get a free case assessement please fill in the following form and send it to us;
please be sure to provide a valid eMail-Address to which we can respond safely.

Basic information:
Your (patient's) full Name:
male  female  age 
If another person is writing for patient - Writer's full name: Mr.  Mrs. 
Your (patient's) home town and country:
Note: Please carefully check your input. If you do not receive an answer, it is very likely due to an errornousely entered eMail address!
Your (patient's) eMail-Address:
Your (patient's) phone/fax:
What kind of original cancer was diagnosed?
Date of first recognized indiations?  month/year


What Therapies have been undertaken:
year:  1st: 
result: 
year:  2nd: 
result: 
year:  3rd: 
result: 
year:  4th: 
result: 
year:  5th: 
result: 
year:  6th: 
result: 


Informationen about condition:
Known metastases existent? If yes: Where?
Pains? If yes: What kind & 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
Patient's current medication:
Other current illnesses:


Patient´s information:
Patient needs special care  ...
Patient could travel  ... to Austria: Yes  No 
Patient would come ... alone  not alone 
Accomodation wanted ...
Patient wants to know ... Chances of treatment by Dr. Kroiss
Estimated duration of treatment in Vienna 
Estimated duration of treatment back home
Estimated Cost of Treatment 
Expected Result 
Personal communication to Dr. Kroiss:



Note: Your data will be treated confidential und not submited to others.

Kroiss-Krebs-Zentrum - Tel.: 43-1-982 57 67 - Fax: 43-1-982 69 92
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