| MAIN FORM BODY |
|INDENT(10)|
|LAST(FOLLOW-UP ATTEMPTS:FOLLOW-UP ATTEMPT DATE)|
|$E(SSN,8,11)|
|LOWERCASE(ONCOFIRSTNAME LASTNAME(LAST FOLLOW-UP CONTACT))||TAB|
|LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 1)|
|WRAP|
|LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 2)|
|LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 3)|
|NOWRAP|
|LOWERCASE(LAST FOLLOW-UP CONTACT:ZIP CODE)|
Dear |SALUTATION|. |LOWERCASE(LAST NAME)|,
Our hospital has a clinical program engaged in following
the progress of our former patients. We are interested in
knowing how you are doing.
Would you be kind enough to answer the questions
listed below? Your assistance will add to the
success of this program and help us achieve better
patient care in our hospital. A self-addressed,
stamped envelope is enclosed for your convenience.
Thank you for your participation.
Sincerely,
|Tumor Registrar|
Tumor Registrar
Today's date:
1. What is your present status?
_____ Free of cancer _____ Not free of cancer
2. Are you able to work or carry on normal activity?
_____ Limited _____ Capable, but limited _____ Incapable
3. Have you seen a doctor outside of the VA Medical Center?
_____ Yes _____ No If "Yes", who and where:
_________________________________________________________
4. If the patient is deceased, please give date and place of death:
_________________________________________________________
5. What was the cause of death? _____ Cancer _____ Not cancer
_____ Other causes (specify) ___________________________
6. Please list any other symptoms relating to your condition not
covered in the above items on the back of this sheet.
|
