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Dear Director:
An integral part of our hospital cancer program involves an
annual follow-up of our patients. The following patient is
being seen at your institution. Would you be so kind as to
DEPARTMENT OF VETERANS AFFAIRS |TODAY|
provide me with the following information for our registry?
A self-addressed stamped envelope is provided for your
convenience.
|NAME|
|$E(SSN,8,11)|
|DOB|
|ICD-O TOPOGRAPHY LIST|
|HOSPITAL NAME|
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
Thank you for your assistance,
|Tumor Registrar|
Tumor Registrar
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