{"aaData": [["TUMOR REGISTRAR DOT MATRIX", "\n|INDENT(5)||NOWRAP|\nyou can give us, even if you did not examine the patient for cancer.\n \n|SETTAB(5,40,60)|\n|TAB|Patient: |LOWERCASE(FIRST-LAST)||TAB|Date of last contact: |LAST(FOLLOW-UP)|\n|TAB|SSN#: |$E(SSN,8,11)| |TAB|Sex: |SEX||TAB|Race: |RACE 1|\n|TAB|Date of Birth: |DOB|\n\n|TAB|Primary Site(s):\n|TAB||ICD-O TOPOGRAPHY LIST|\n____________________________________________________________________\n|HOSPITAL NAME| |TODAY|\n \nStatus of Patient-\n ( ) Alive - Date of your last contact __/__/__ (MM/DD/YY)\n ( ) Normal activity w/o symptoms ( ) Bedridden or hospitalized\n ( ) Symptomatic but ambulatory ( ) Unknown\n \n ( ) Dead - Date of Death: __/__/__ (MM/DD/YY)\n Cause of Death: ____________________________\n Autopsy: ( ) Yes ( ) No Cancer Related ( ) Yes ( ) No\n \n|HOSPITAL STREET ADDRESS| \nStatus of Cancer-\n ( ) No Evidence of Disease ( ) Recurrent Disease __/__ (MM/YY)\n ( ) Residual Disease Site ________________\n ( ) Metastatic Disease Local ( )\n ( ) In Remission Regional ( )\n ( ) Tumor Status Unknown Distant ( )\n \nTreatments since last follow-up:\n ( ) Surgery ( ) Chemotherapy Date of Treatment __/__ (MM/YY)\n ( ) Radiation ( ) Immunotherapy ( ) Other\n|HOSPITAL CITY,ST ZIP| \n \nIf a treatment type is checked, would you please specify the nature of\nthe actual treatment on the back of this form?\n \nStage of Disease-\n Solid Tumors: ( ) In situ ( ) Localized ( ) Regional, Dir. Ext.\n ( ) Reg. Nodes ( ) Both nodes & ext. ( ) Reg., NOS ( ) Distant\n ( ) Unknown ( ) Not applicable\n \nIf the patient has moved and/or is being seen by another physician, would \n \nyou please give us the new names, addresses, and phone numbers on the \nback of this form so that we may continue following this patient?\n \n Thank you for your assistance,\n\n Tumor Registry\nDear Tumor Registrar:\n \nAn annual follow-up of patients is required as part of our Medical \nCenter's Cancer Program. We would appreciate any information\n
\n\n", "TUMOR REGISTRAR\n", ""], ["PATIENT DOT MATRIX", "\n \n|LAST(FOLLOW-UP ATTEMPTS:FOLLOW-UP ATTEMPT DATE)|\n \n \n \n|LOWERCASE(ONCOFIRSTNAME LASTNAME(LAST FOLLOW-UP CONTACT))||TAB|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 1)|\n|WRAP|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 2)|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 3)|\n|NOWRAP|\n|INDENT(10)|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:ZIP CODE)|\n \nDear |SALUTATION|. |LOWERCASE(LAST NAME)|,\n \nOur hospital has a clinical program engaged in following\nthe progress of our former patients. We are interested in\nknowing how you are doing.\n \nWould you be kind enough to answer the questions\nlisted below? Your assistance will add to the\n DEPARTMENT OF VETERANS AFFAIRS \nsuccess of this program and help us achieve better \npatient care in our hospital. A self-addressed,\nstamped envelope is enclosed for your convenience.\n \nThank you for your participation.\n \n Sincerely,\n \n |Tumor Registrar|\n Tumor Registrar\n |HOSPITAL NAME|\n \n \nToday's date: \n \n1. What is your present status?\n _____ Free of cancer _____ Not free of cancer\n \n2. Are you able to work or carry on normal activity?\n _____ Limited _____ Capable, but limited _____ Incapable\n \n |HOSPITAL STREET ADDRESS|\n3. Have you seen a doctor outside of the VA Medical Center?\n _____ Yes _____ No If "Yes", who and where:\n _________________________________________________________\n \n4. If the patient is deceased, please give date and place of death:\n _________________________________________________________\n \n5. What was the cause of death? _____ Cancer _____ Not cancer\n _____ Other causes (specify) ___________________________\n \n |HOSPITAL CITY,ST ZIP|\n6. Please list any other symptoms relating to your condition not\n covered in the above items on the back of this sheet.\n \n \n \n
\n\n", "PATIENT\n", ""], ["PHYSICIAN DOT MATRIX", "\n|INDENT(5)||NOWRAP|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 3)||NOWRAP|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:ZIP CODE)|\n \nDear Dr. |LOWERCASE(ONCOLASTNAME(LAST FOLLOW-UP CONTACT))|, \n \nFollow-up of cases entered into our Tumor Registry is conducted annually.\nPlease fill in the appropriate statements below and return in the enclosed\nenvelope. If you have had no contact with this patient, a negative reply\nis helpful and will avoid our sending you further inquiries. Thank you.\n|NOWRAP| \nDEPARTMENT OF VETERANS AFFAIRS |TODAY|\nPatient Name: |LOWERCASE(FIRST-LAST)|\nDate of Last Contact: |LAST(FOLLOW-UP)|\nDate of Birth: |DOB| SSN: |$E(SSN,8,11)| \nSite(s) of Malignancy:\n\n|ICD-O TOPOGRAPHY LIST|\nDate your last information__________Alive__________Dead__________\nBasis of information: Exam_____Letter/Phone_____Other Specify___\nStatus of cancer: No clinical evidence__________________________\n Residual cancer_______________________________\n|HOSPITAL NAME|\n Local recurrence______________________________\n Metastatic to_________________________________\n Unknown_______________________________________\n New Primary site______________________________\nTreatment(Specify None_________________________________________\nDates & Type): Surgery______________________________________\n Radiation____________________________________\n Chemotherapy_________________________________\n Other________________________________________\nQuality of survival: Normal Less than 50% Ambulatory\n|HOSPITAL STREET ADDRESS|\n(Circle One) Symptomatic & Ambulatory Bedridden\n More than 50% Ambulatory Unknown\nDeath: Date_____Place___________________________________________\n Cause____________________________________________________\nAutopsy: YES_____NO_____Was cancer present?_____________________\nInformation: Patient's new address______________________________\n New Physician______________________________________\n New Physician's address____________________________\nRemarks:\n \n|HOSPITAL CITY,ST ZIP|\n \n Sincerely,\n\n\n\n |Tumor Registrar|\n Tumor Registrar\n \n|LOWERCASE(ONCOFIRSTNAME LASTNAME(LAST FOLLOW-UP CONTACT))|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 1)||WRAP|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 2)|\n
\n\n", "PHYSICIAN\n", "\nPhysician letter used at Sioux Falls.\n
\n\n"], ["DEATH INQUIRY DOT MATRIX", "\n|INDENT(5)||NOWRAP|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:ZIP CODE)|\n \n|NAME| |$E(SSN,8,11)| |DOB||NOWRAP|\n|NOBLANKLINE||STREET ADDRESS 1|\n|ZIP CODE|\n|WRAP|\n\n|ICD-O TOPOGRAPHY LIST|\n \nFrom the Tumor Registrar,\n|HOSPITAL NAME| |TODAY|\n \n We recently learned of the death of the person listed above. In \norder that our follow-up may be complete, please provide the \ninformation below and return to us in the enclosed envelope.\n \n Date of Death:\n \n Place of Death:\n \n Cause of Death:\n|HOSPITAL STREET ADDRESS|\n \n Was there an autopsy?\n \n In order to update our tumor registry abstract, please list any\ntreatment: |LAST(FOLLOW-UP:DATE OF LAST CONTACT OR DEATH)|. \n \n \n \n \n \n|HOSPITAL CITY,ST ZIP| \n Your assistance in making our tumor registry complete and valuable \nis appreciated. \n \n |Tumor Registrar|\n Tumor Registrar\n |TR PHONE NUMBER|\n \n|LOWERCASE(ONCOLASTNAME(LAST FOLLOW-UP CONTACT))|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 1)||WRAP|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 2)|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 3)||NOWRAP|\n
\n\n", "DEATH INQUIRY\n", "\nThis letter is used to inquire to the Bureau of Vital Statistics regarding\nthe death of a cancer patient. This will enable the information to be\nobtained from a "disinterested" party, rather than going to the next-of-kin.\n
\n\n"], ["DEATH INQUIRY LASER PRINTER", "\n|INDENT(5)||NOWRAP|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 1)||WRAP|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 2)|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 3)||NOWRAP|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:ZIP CODE)|\n \n \n|NAME| |$E(SSN,8,11)| |DOB||NOWRAP|\n|NOBLANKLINE||STREET ADDRESS 1|\n|ZIP CODE|\n|WRAP|\n |TODAY|\n\n|ICD-O TOPOGRAPHY LIST|\n \nFrom the Tumor Registrar,\n \n \n We recently learned of the death of the person listed above. In\norder that our follow-up may be complete, please provide the \ninformation below and return to us in the enclosed envelope.\n \n \n Date of Death:\n \n Place of Death:\n \n Cause of Death:\n \n Was there an autopsy?\n \n In order to update our tumor registry abstract, please list any\ntreatments since |LAST(FOLLOW-UP:DATE OF LAST CONTACT OR DEATH)|.\n \n \n \n \n Your assistance in making our tumor registry complete and valuable\nis appreciated.\n |Tumor Registrar| \n Tumor Registrar\n |TR PHONE NUMBER|\n \n \n\n \n|LOWERCASE(ONCOLASTNAME(LAST FOLLOW-UP CONTACT))|\n
\n\n", "DEATH INQUIRY\n", ""], ["NEXT OF KIN LASER PRINTER", "\n \n|INDENT(10)|\n|TODAY|\n \n \n \n \n|LOWERCASE(ONCOFIRSTNAME LASTNAME(LAST FOLLOW-UP CONTACT))||TAB|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 1)|\n|WRAP|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 2)|\n \n|LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 3)|\n|NOWRAP|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:ZIP CODE)|\n \n \n \nDear |LOWERCASE(LAST FOLLOW-UP CONTACT:TITLE)| |LOWERCASE(ONCOLASTNAME(LAST FOLLOW-UP CONTACT))|,\n \nOur hospital has a clinical program which is engaged\nin following the progress of our former patients. We\n \nare interested in knowing about the following person:\n \n |NAME|\n \nWould you be kind enough to complete the information\nrequested below? Your assistance will add to the\nsuccess of this program and help us achieve better\npatient care at our hospital. A self-addressed,\nstamped envelope is enclosed for your convenience.\n \n \nThank you for your assistance.\n \n Sincerely,\n \n \n \n |Tumor Registrar|\n Tumor Registrar\n \n \n \nPresent whereabouts of: |NAME|\n \n Address:\n \nDoctor who is now caring for this person:\n \n Name:\n Address:\n \n Name: |NAME|\n \n SSN: |$E(SSN,8,11)| \n \n \n \n
\n\n", "NEXT OF KIN\n", ""], ["PATIENT LASER PRINTER", "\n|INDENT(10)|\n|LAST(FOLLOW-UP ATTEMPTS:FOLLOW-UP ATTEMPT DATE)|\n |$E(SSN,8,11)| \n \n \n \n \n|LOWERCASE(ONCOFIRSTNAME LASTNAME(LAST FOLLOW-UP CONTACT))||TAB|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 1)|\n|WRAP|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 2)|\n \n|LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 3)|\n|NOWRAP|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:ZIP CODE)|\n \nDear |SALUTATION|. |LOWERCASE(LAST NAME)|,\n \nOur hospital has a clinical program engaged in following\nthe progress of our former patients. We are interested in\nknowing how you are doing.\n \n \nWould you be kind enough to answer the questions\nlisted below? Your assistance will add to the\nsuccess of this program and help us achieve better\npatient care in our hospital. A self-addressed,\nstamped envelope is enclosed for your convenience.\n \nThank you for your participation.\n \n Sincerely,\n \n \n |Tumor Registrar|\n Tumor Registrar\n \n \nToday's date:\n \n1. What is your present status?\n _____ Free of cancer _____ Not free of cancer\n \n2. Are you able to work or carry on normal activity?\n \n _____ Limited _____ Capable, but limited _____ Incapable\n \n3. Have you seen a doctor outside of the VA Medical Center?\n _____ Yes _____ No If "Yes", who and where:\n _________________________________________________________\n \n4. If the patient is deceased, please give date and place of death:\n _________________________________________________________\n \n5. What was the cause of death? _____ Cancer _____ Not cancer\n \n _____ Other causes (specify) ___________________________\n \n6. Please list any other symptoms relating to your condition not\n covered in the above items on the back of this sheet.\n \n \n \n
\n\n", "PATIENT\n", ""], ["PHYSICIAN LASER PRINTER", "\n|INDENT(5)||NOWRAP|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 1)||WRAP|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 2)|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 3)||NOWRAP|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:ZIP CODE)|\n \nDear Dr. |LOWERCASE(ONCOLASTNAME(LAST FOLLOW-UP CONTACT))|, \n \nFollow-up of cases entered into our Tumor Registry is conducted annually.\nPlease fill in the appropriate statements below and return in the enclosed\nenvelope. If you have had no contact with this patient, a negative reply\n\nis helpful and will avoid our sending you further inquiries. Thank you.\n|NOWRAP| \nPatient Name: |LOWERCASE(FIRST-LAST)|\nDate of Last Contact: |LAST(FOLLOW-UP)|\nDate of Birth: |DOB| SSN: |$E(SSN,8,11)| \nSite(s) of Malignancy:\n\n|ICD-O TOPOGRAPHY LIST|\nDate your last information__________Alive__________Dead__________\nBasis of information: Exam_____Letter/Phone_____Other Specify___\n |TODAY|\nStatus of cancer: No clinical evidence__________________________\n Residual cancer_______________________________\n Local recurrence______________________________\n Metastatic to_________________________________\n Unknown_______________________________________\n New Primary site______________________________\nTreatment(Specify None_________________________________________\nDates & Type): Surgery______________________________________\n Radiation____________________________________\n Chemotherapy_________________________________\n\n Other________________________________________\nQuality of survival: Normal Less than 50% Ambulatory\n(Circle One) Symptomatic & Ambulatory Bedridden\n More than 50% Ambulatory Unknown\nDeath: Date_____Place___________________________________________\n Cause____________________________________________________\nAutopsy: YES_____NO_____Was cancer present?_____________________\nInformation: Patient's new address______________________________\n New Physician______________________________________\n New Physician's address____________________________\n\nRemarks:\n \n \n Sincerely,\n\n\n \n |Tumor Registrar|\n Tumor Registrar\n\n\n\n|LOWERCASE(ONCOFIRSTNAME LASTNAME(LAST FOLLOW-UP CONTACT))|\n
\n\n", "PHYSICIAN\n", ""], ["TUMOR REGISTRAR LASER PRINTER", "\n|INDENT(5)||NOWRAP|\n \nAn annual follow-up of patients is required as part of our Medical \nCenter's Cancer Program. We would appreciate any information\nyou can give us, even if you did not examine the patient for cancer.\n \n|SETTAB(5,40,60)|\n|TAB|Patient: |LOWERCASE(FIRST-LAST)||TAB|Date of last contact: |LAST(FOLLOW-UP)|\n|TAB|SSN#: |$E(SSN,8,11)| |TAB|Sex: |SEX||TAB|Race: |RACE 1|\n|TAB|Date of Birth: |DOB|\n\n |TODAY|\n|TAB|Primary Site(s):\n|TAB||ICD-O TOPOGRAPHY LIST|\n____________________________________________________________________\n \nStatus of Patient-\n ( ) Alive - Date of your last contact __/__/__ (MM/DD/YY)\n ( ) Normal activity w/o symptoms ( ) Bedridden or hospitalized\n ( ) Symptomatic but ambulatory ( ) Unknown\n \n ( ) Dead - Date of Death: __/__/__ (MM/DD/YY)\n \n Cause of Death: ____________________________\n Autopsy: ( ) Yes ( ) No Cancer Related ( ) Yes ( ) No\n \nStatus of Cancer-\n ( ) No Evidence of Disease ( ) Recurrent Disease __/__ (MM/YY)\n ( ) Residual Disease Site ________________\n ( ) Metastatic Disease Local ( )\n ( ) In Remission Regional ( )\n ( ) Tumor Status Unknown Distant ( )\n \n\nTreatments since last follow-up:\n ( ) Surgery ( ) Chemotherapy Date of Treatment __/__ (MM/YY)\n ( ) Radiation ( ) Immunotherapy ( ) Other\n \nIf a treatment type is checked, would you please specify the nature of\nthe actual treatment on the back of this form?\n \nStage of Disease-\n Solid Tumors: ( ) In situ ( ) Localized ( ) Regional, Dir. Ext.\n ( ) Reg. Nodes ( ) Both nodes & ext. ( ) Reg., NOS ( ) Distant\n\n ( ) Unknown ( ) Not applicable\n \nIf the patient has moved and/or is being seen by another physician, would \nyou please give us the new names, addresses, and phone numbers on the \nback of this form so that we may continue following this patient?\n \n Thank you for your assistance,\n\n Tumor Registry\n\n\n\nDear Tumor Registrar:\n
\n\n", "TUMOR REGISTRAR\n", ""], ["INSTITUTION DOT MATRIX", "\n|INDENT(5)||NOWRAP|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 1)||WRAP|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 2)|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 3)||NOWRAP|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:ZIP CODE)|\n \nDear Director:\n \nAn integral part of our hospital cancer program involves an\nannual follow-up of our patients. The following patient is\nbeing seen at your institution. Would you be so kind as to\nDEPARTMENT OF VETERANS AFFAIRS |TODAY|\nprovide me with the following information for our registry?\nA self-addressed stamped envelope is provided for your\nconvenience.\n \n|NAME|\n|$E(SSN,8,11)| \n|DOB|\n\n\n|ICD-O TOPOGRAPHY LIST|\n|HOSPITAL NAME|\n\nStatus of Patient-\n ( ) Alive - Date of your last contact __/__/__ (MM/DD/YY)\n ( ) Normal activity w/o symptoms ( ) Bedridden or hospitalized\n ( ) Symptomatic but ambulatory ( ) Unknown\n \n ( ) Dead - Date of Death: __/__/__ (MM/DD/YY)\n Cause of Death: ____________________________\n Autopsy: ( ) Yes ( ) No Cancer Related ( ) Yes ( ) No\n \n|HOSPITAL STREET ADDRESS|\nStatus of Cancer-\n ( ) No Evidence of Disease ( ) Recurrent Disease __/__ (MM/YY)\n ( ) Residual Disease Site ________________\n ( ) Metastatic Disease Local ( )\n ( ) In Remission Regional ( )\n ( ) Tumor Status Unknown Distant ( )\n \nTreatments since last follow-up:\n ( ) Surgery ( ) Chemotherapy Date of Treatment __/__ (MM/YY)\n ( ) Radiation ( ) Immunotherapy ( ) Other\n|HOSPITAL CITY,ST ZIP|\n \nIf a treatment type is checked, would you please specify the nature of\nthe actual treatment on the back of this form?\n \nStage of Disease-\n Solid Tumors: ( ) In situ ( ) Localized ( ) Regional, Dir. Ext.\n ( ) Reg. Nodes ( ) Both nodes & ext. ( ) Reg., NOS ( ) Distant\n ( ) Unknown ( ) Not applicable\n \n Thank you for your assistance,\n \n \n\n\n |Tumor Registrar|\n Tumor Registrar\n|LAST(FOLLOW-UP ATTEMPTS:FOLLOW-UP ATTEMPT DATE)|\n \n|LOWERCASE(ONCOLASTNAME(LAST FOLLOW-UP CONTACT))|\n
\n\n", "INSTITUTION\n", ""], ["INSTITUTION LASER PRINTER", "\n|INDENT(5)||NOWRAP|\n \n|LOWERCASE(ONCOLASTNAME(LAST FOLLOW-UP CONTACT))|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 1)||WRAP|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 2)|\n|NOBLANKLINE||LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 3)||NOWRAP|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:ZIP CODE)|\n \nDear Director:\n \nAn integral part of our hospital cancer program involves an\n |TODAY|\nannual follow-up of our patients. The following patient is\nbeing seen at your institution. Would you be so kind as to\nprovide me with the following information for our registry?\nA self-addressed stamped envelope is provided for your\nconvenience.\n \n|NAME|\n|$E(SSN,8,11)| \n|DOB|\n\n\n\n|ICD-O TOPOGRAPHY LIST|\n\nStatus of Patient-\n ( ) Alive - Date of your last contact __/__/__ (MM/DD/YY)\n ( ) Normal activity w/o symptoms ( ) Bedridden or hospitalized\n ( ) Symptomatic but ambulatory ( ) Unknown\n \n ( ) Dead - Date of Death: __/__/__ (MM/DD/YY)\n Cause of Death: ____________________________\n\n Autopsy: ( ) Yes ( ) No Cancer Related ( ) Yes ( ) No\n \nStatus of Cancer-\n ( ) No Evidence of Disease ( ) Recurrent Disease __/__ (MM/YY)\n ( ) Residual Disease Site ________________\n ( ) Metastatic Disease Local ( )\n ( ) In Remission Regional ( )\n ( ) Tumor Status Unknown Distant ( )\n \nTreatments since last follow-up:\n\n ( ) Surgery ( ) Chemotherapy Date of Treatment __/__ (MM/YY)\n ( ) Radiation ( ) Immunotherapy ( ) Other\n \nIf a treatment type is checked, would you please specify the nature of\nthe actual treatment on the back of this form?\n \nStage of Disease-\n Solid Tumors: ( ) In situ ( ) Localized ( ) Regional, Dir. Ext.\n ( ) Reg. Nodes ( ) Both nodes & ext. ( ) Reg., NOS ( ) Distant\n ( ) Unknown ( ) Not applicable\n\n \n Thank you for your assistance,\n \n\n\n |Tumor Registrar|\n Tumor Registry\n\n\n|LAST(FOLLOW-UP ATTEMPTS:FOLLOW-UP ATTEMPT DATE)|\n
\n\n", "INSTITUTION\n", ""], ["NEXT OF KIN DOT MATRIX", "\n \n \n |LAST(FOLLOW-UP ATTEMPTS:FOLLOW-UP ATTEMPT DATE)|\n \n \n \n|LOWERCASE(ONCOFIRSTNAME LASTNAME(LAST FOLLOW-UP CONTACT))||TAB|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 1)|\n|WRAP|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 2)|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:STREET ADDRESS 3)|\n \n|NOWRAP|\n|LOWERCASE(LAST FOLLOW-UP CONTACT:ZIP CODE)|\n \nDear |LOWERCASE(ONCOFIRSTNAME LASTNAME(LAST FOLLOW-UP CONTACT))|,\n \nOur hospital has a clinical program which is engaged\nin following the progress of our former patients. We\nare interested in knowing about the following person:\n \n |FIRST-LAST|\n \n \nWould you be kind enough to complete the information\nrequested below? Your assistance will add to the\nsuccess of this program and help us achieve better\npatient care at our hospital. A self-addressed,\nstamped envelope is enclosed for your convenience.\n \nThank you for your assistance.\n \n Sincerely,\n|INDENT(15)|\n \n \n \n \n |Tumor Registrar|\n Tumor Registrar\n \n \n \nPresent whereabouts of: |LOWERCASE(FIRST-LAST)|\n|C. HOSPITAL NAME| \n \n Address:\n \n \nDoctor who is now caring for this person:\n \n Name:\n Address:\n \n Name: |FIRST-LAST|\n |HOSPITAL STREET ADDRESS|\n SSN: |$E(SSN,8,11)| \n \n |HOSPITAL CITY,ST ZIP|\n \n \n
\n\n", "NEXT OF KIN\n", ""]]}