| MAIN FORM BODY |
|INDENT(5)||NOWRAP|
|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 3)||NOWRAP|
|LOWERCASE(LAST FOLLOW-UP CONTACT:ZIP CODE)|
Dear Dr. |LOWERCASE(ONCOLASTNAME(LAST FOLLOW-UP CONTACT))|,
Follow-up of cases entered into our Tumor Registry is conducted annually.
Please fill in the appropriate statements below and return in the enclosed
envelope. If you have had no contact with this patient, a negative reply
is helpful and will avoid our sending you further inquiries. Thank you.
|NOWRAP|
DEPARTMENT OF VETERANS AFFAIRS |TODAY|
Patient Name: |LOWERCASE(FIRST-LAST)|
Date of Last Contact: |LAST(FOLLOW-UP)|
Date of Birth: |DOB| SSN: |$E(SSN,8,11)|
Site(s) of Malignancy:
|ICD-O TOPOGRAPHY LIST|
Date your last information__________Alive__________Dead__________
Basis of information: Exam_____Letter/Phone_____Other Specify___
Status of cancer: No clinical evidence__________________________
Residual cancer_______________________________
|HOSPITAL NAME|
Local recurrence______________________________
Metastatic to_________________________________
Unknown_______________________________________
New Primary site______________________________
Treatment(Specify None_________________________________________
Dates & Type): Surgery______________________________________
Radiation____________________________________
Chemotherapy_________________________________
Other________________________________________
Quality of survival: Normal Less than 50% Ambulatory
|HOSPITAL STREET ADDRESS|
(Circle One) Symptomatic & Ambulatory Bedridden
More than 50% Ambulatory Unknown
Death: Date_____Place___________________________________________
Cause____________________________________________________
Autopsy: YES_____NO_____Was cancer present?_____________________
Information: Patient's new address______________________________
New Physician______________________________________
New Physician's address____________________________
Remarks:
|HOSPITAL CITY,ST ZIP|
Sincerely,
|Tumor Registrar|
Tumor Registrar
|LOWERCASE(ONCOFIRSTNAME LASTNAME(LAST FOLLOW-UP CONTACT))|
|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 1)||WRAP|
|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 2)|
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