|
Post a reply ||
Back to DeLiver A Cure - Message Board
Re: Questionnaire
Submitted by Amy on 03/Jan/2009 in reply to Questionnaire posted by Amy on 03/Jan/2009
98.235.196.151
Message:
FIBROLAMELLAR CARCINOMA QUESTIONNAIRE
If you do not understand a question or you do not feel comfortable in answering a question, leave it blank and go on to the next question. Some questions may not apply to you.
DOB:
AGE:
DATE OF DIAGNOSIS:
PAST MEDICAL HISTORY:
FIBROLAMELLAR MEDICAL HISTORY:
PAST SURGICAL HISTORY:
FIBROLAMELLAR SURGICAL HISTORY:
SOCIAL HISTORY (Please be honest and include drug, alcohol, tobacco history with length of time included)
FAMILY MEDICAL HISTORY: (Please include parents, grandparents and aunts and uncles—specific to cancer history)
MEDICATIONS TAKEN PRIOR TO FIBROLAMELLAR DIAGNOSIS
MEDICATIONS TAKEN SINCE DIAGNOSIS OF FIBROLAMELLAR
ALLERGIES
DEMOGRAPHIC HISTORY (Where you have lived, is there any power plants near by)
HEALTH REVIEW
SKIN:
EYES:
MOUTH:
NECK:
LUNGS:
HEART:
GASTROINTESTINAL:
Nausea or vomiting?
Constipation?
Change in bowel habits?
Change in appetite?
Any liver or colon problems?
JOINTS / EXTREMITIES:
NEUROLOGIC:
BLOOD:
Any history of anemia or blood disorder?
DOCTORS YOU HAVE SEEN:
RECOMMENDED TREATMENT:
CHEMOTHERAPEUTIC AGENTS PRESCRIBED: (Please use none if applicable)
RECOMMENDED FOLLOW-UP TIME BETWEEN SCANS AND PLEASE SPECIFY CATSCAN/MRI OR PETSCAN:
Replies to this post
|
