Followup

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Followup Powered By Docstoc
					MRN ___________________
                                               Followup Event

                     MRN
                     First name
                     Last name
        Date of visit (mm/dd/yy)
        ECOG Score (see appendix)
        Karnofsky Score (see appendix)
        New Symptoms/Complaints (0=No, 1=Yes)
        Comments


        Weight (kg)
        Cr (mg/dL)
        GFR (ml/min)
        Ca (mg/dL)
        Albumin (g/dL)
        Alk Phos (u/L)
        ALT (u/L)
        AST (u/L)
        Hgb (g/dL)
        Platelets (10^9/L)
        LDH (u/L)


        Date of imaging (mm/dd/yy)
        Abdominal imaging modality (1=CT, 2=MRI, 3=US)
        KIDNEY
        Nx or Partial Nx (1=No evidence of recurrence, 2=Local recurrence)

        Cryoablation (3=No enhancement, 4=Peripheral enhancement, 5=Non-peripheral
        enhancement/continued mass enhancement)

        AS (6=Continue surveillance, 7=Proceed to treatment due to size increase, 8= Proceed to
        treatment due to pt request, 9=Discontinue surveillance due to patient choice,
        10=Discontinue surveillance due to comorbidity, 11=Discontinue surveillance due to size
        stability)

        12=Metastatic tumor
        Size of residual lesion (mm)     IF CRYOABLATION or ACTIVE SURVEILLANCE

        Date of imaging (mm/dd/yy)
        Chest imaging (0=no, 1=yes)
           If yes list (1=CXR, 2=CT, 3=MRI)

        Comments
MRN ___________________

        Drug
        Dose
        Need for drug/dosage change
MRN ___________________

        #1 Met Site (1=Lung, 2=LN abdomen, 3=LN chest, 4=Adrenal, 5=Bone, 6=Liver, 7=Brain
        Tumor size (mm)
        Biopsy (0=Not done, 1=RCC, 2=Non diagnostic, 3=Benign, 4=Other Malig)
        Comment:

        #2 Met Site (1=Lung, 2=LN abdomen, 3=LN chest, 4=Adrenal, 5=Bone, 6=Liver, 7=Brain
        Tumor size (mm)
        Biopsy (0=Not done, 1=RCC, 2=Non diagnostic, 3=Benign, 4=Other Malig)
        Comment:

        #3 Met Site (1=Lung, 2=LN abdomen, 3=LN chest, 4=Adrenal, 5=Bone, 6=Liver, 7=Brain
        Tumor size (mm)
        Biopsy (0=Not done, 1=RCC, 2=Non diagnostic, 3=Benign, 4=Other Malig)
        Comment:

        #4 Met Site (1=Lung, 2=LN abdomen, 3=LN chest, 4=Adrenal, 5=Bone, 6=Liver, 7=Brain
        Tumor size (mm)
        Biopsy (0=Not done, 1=RCC, 2=Non diagnostic, 3=Benign, 4=Other Malig)
        Comment:

        #5 Met Site (1=Lung, 2=LN abdomen, 3=LN chest, 4=Adrenal, 5=Bone, 6=Liver, 7=Brain
        Tumor size (mm)
        Biopsy (0=Not done, 1=RCC, 2=Non diagnostic, 3=Benign, 4=Other Malig)
        Comment:

        #6 Met Site (1=Lung, 2=LN abdomen, 3=LN chest, 4=Adrenal, 5=Bone, 6=Liver, 7=Brain
        Tumor size (mm)
        Biopsy (0=Not done, 1=RCC, 2=Non diagnostic, 3=Benign, 4=Other Malig)
        Comment:

        #7 Met Site (1=Lung, 2=LN abdomen, 3=LN chest, 4=Adrenal, 5=Bone, 6=Liver, 7=Brain
        Tumor size (mm)
        Biopsy (0=Not done, 1=RCC, 2=Non diagnostic, 3=Benign, 4=Other Malig)
        Comment:

        #8 Met Site (1=Lung, 2=LN abdomen, 3=LN chest, 4=Adrenal, 5=Bone, 6=Liver, 7=Brain
        Tumor size (mm)
        Biopsy (0=Not done, 1=RCC, 2=Non diagnostic, 3=Benign, 4=Other Malig)
        Comment:

        #9 Met Site (1=Lung, 2=LN abdomen, 3=LN chest, 4=Adrenal, 5=Bone, 6=Liver, 7=Brain
        Tumor size (mm)
        Biopsy (0=Not done, 1=RCC, 2=Non diagnostic, 3=Benign, 4=Other Malig)
        Comment:
MRN ___________________
         #10 Met Site (1=Lung, 2=LN abdomen, 3=LN chest, 4=Adrenal, 5=Bone, 6=Liver, 7=Brain
         Tumor size (mm)
         Biopsy (0=Not done, 1=RCC, 2=Non diagnostic, 3=Benign, 4=Other Malig)
         Comment:
Use RECIST Criteria (Therasse et al., JNCI, Feb 2000, pg 205)
         Document up to 10 sites, including at least one site from each affected organ
         Use largest diameter of metastatic site

				
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posted:10/15/2011
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