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Requested
Illustration:
1. TYPE OF MALIGNANCY OR CANCER?
BLADDER
BREAST
CERVICAL
COLON OR
RECTAL (ALSO COMPLETE QUESTION #7)
HODGKIN'S DISEASE
MELANOMA (ALSO COMPLETE QUESTION #8)
PROSTATE (ALSO COMPLETE QUESTION #9)
SKIN, MELANOMA, PLEASE DETAIL:
Other, Type
Location on Body
2. HAS TUMOR OR MALIGNANCY METASTASIZED?
PLEASE DETAIL:
DATE DIAGNOSED:
Month
Year
3. STAGE OF TUMOR OR MALIGNANCY:
T
N
M
OR
1
2
2A
2B
3
3A
3B
4
5
OTHER
4. TYPES OF TREATMENT USED: (CHECK ALL APPLICABLE)
SURGICAL REMOVAL OF MALIGNANCY
CHEMOTHERAPY
RADIATION THERAPY
HORMONAL OR
CHIDECTOMY - DES. LUPRON
OTHER
5. DATE OF LAST TREATMENT RECEIVED:
Month
Year
6. HAS THERE BEEN ANY MEDICAL EVIDENCE OF RECURRENT CANCER?
IF YES, PLEASE DETAIL:
Month
Year
7. DUKE'S SCALE: (FOR COLON OR RECTAL CANCER ONLY)
A
B1
C1
C2
D
8. CLARK'S LEVEL (FOR MELANOMA ONLY):
I
II
III
IV
V
DEPTH OF MELANOMA
9. (FOR PROSTATE CANCER ONLY) STAGE;
T
N
M
OR
1
2
2A
2B
3
3A
3B
4
5
GLEASON'S GRADE:
2 OR 3
4 OR 5
6 OR MORE
RESULTS OF MOST RECENT PSA TEST?
10. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
IF YES, PLEASE DETAIL
11. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
IF YES, PLEASE DETAIL
12. CLIENT'S OCCUPATION
13. PLEASE LIST ANY OTHER ILLNESSES OR
IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH:
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