PHYSICIAN DOT MATRIX (18)    FOLLOW-UP FORM LETTER (165.1)

Name Value
NAME PHYSICIAN DOT MATRIX
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)|
FORM TYPE PHYSICIAN
DESCRIPTION
Physician letter used at Sioux Falls.