| MAIN FORM BODY |
|INDENT(5)||NOWRAP|
you can give us, even if you did not examine the patient for cancer.
|SETTAB(5,40,60)|
|TAB|Patient: |LOWERCASE(FIRST-LAST)||TAB|Date of last contact: |LAST(FOLLOW-UP)|
|TAB|SSN#: |$E(SSN,8,11)| |TAB|Sex: |SEX||TAB|Race: |RACE 1|
|TAB|Date of Birth: |DOB|
|TAB|Primary Site(s):
|TAB||ICD-O TOPOGRAPHY LIST|
____________________________________________________________________
|HOSPITAL NAME| |TODAY|
Status of Patient-
( ) Alive - Date of your last contact __/__/__ (MM/DD/YY)
( ) Normal activity w/o symptoms ( ) Bedridden or hospitalized
( ) Symptomatic but ambulatory ( ) Unknown
( ) Dead - Date of Death: __/__/__ (MM/DD/YY)
Cause of Death: ____________________________
Autopsy: ( ) Yes ( ) No Cancer Related ( ) Yes ( ) No
|HOSPITAL STREET ADDRESS|
Status of Cancer-
( ) No Evidence of Disease ( ) Recurrent Disease __/__ (MM/YY)
( ) Residual Disease Site ________________
( ) Metastatic Disease Local ( )
( ) In Remission Regional ( )
( ) Tumor Status Unknown Distant ( )
Treatments since last follow-up:
( ) Surgery ( ) Chemotherapy Date of Treatment __/__ (MM/YY)
( ) Radiation ( ) Immunotherapy ( ) Other
|HOSPITAL CITY,ST ZIP|
If a treatment type is checked, would you please specify the nature of
the actual treatment on the back of this form?
Stage of Disease-
Solid Tumors: ( ) In situ ( ) Localized ( ) Regional, Dir. Ext.
( ) Reg. Nodes ( ) Both nodes & ext. ( ) Reg., NOS ( ) Distant
( ) Unknown ( ) Not applicable
If the patient has moved and/or is being seen by another physician, would
you please give us the new names, addresses, and phone numbers on the
back of this form so that we may continue following this patient?
Thank you for your assistance,
Tumor Registry
Dear Tumor Registrar:
An annual follow-up of patients is required as part of our Medical
Center's Cancer Program. We would appreciate any information
|
