CES-12, Hematology/Oncology Physician Report
|New Jersey Department of Health |FOR OFFICE USE ONLY |
|Cancer Epidemiology Services | |
|P.O. Box 369, Trenton, NJ 08625-0369 | |
|Telephone Number (609) 633-0500 / Fax Number (609) 633-7509 | |
|HEMATOLOGY/ONCOLOGY PHYSICIAN REPORT (09700) | |
| |CTR #: ______________ |
| | |
|Practice Name: | |
|Physician Name: | |
|Street Address: | |
|City, State, Zip Code: | |
|Telephone / Fax: | |
| |
| | | | | |
|Patient Name | |Date of Birth | |Social Security Number |
| | | | | | | |
|Patient Address | |Race/Ethnicity | |Marital Status | |Sex |
| | | | | |
|City, State, Zip Code | |Occupation | |Industry |
|Primary Site/Laterality of this cancer (attach pathology report): | |
|Histology Type of this cancer: | |
|Date this cancer was FIRST DIAGNOSED: | / / | |
| |Month/Day/Year | |
|Initial visit for this cancer: | / / | |Most recent visit for this cancer: | / / |
| |Month/Day/Year | | |Month/Day/Year |
|STAGE INFORMATION (Please refer to AJCC Cancer Staging Manual.) |
|Primary Tumor (T) | |Regional Lymph Nodes(N) | |Distant Metastases (M) | |
|Tumor Size: | |Systemic Symptoms at Dx: | |IPI Score | |
|Stage @ Diagnosis: | |Lymph Node Status @ Dx: | |
|Tumor Markers: | | | |
| |Name | |Results |
| |
|Did this patient receive any treatment for this cancer? |Yes No |If “Yes,” please complete the following: |
|Active Surveillance/watchful waiting? |Yes No | |
| | | |/ | |/ | |
|Surgery (specify type) | | Month Day Year |
| | | |/ | |/ | |
|Chemotherapy (specify agents, amount, duration) | | Month Day Year |
| | | |/ | |/ | |
|Radiation Therapy (specify amount, method, duration) | | Month Day Year |
| | | |/ | |/ | |
|Immunotherapy (specify type, duration) | | Month Day Year |
| | | |/ | |/ | |
|Hematologic Transplant and Endocrine Procedures | | Month Day Year |
| | | |/ | |/ | |
|Hormone/Other Treatment (specify type, amount, duration) | | Month Day Year |
|Referred to Physician/Hospital: |
| |
| Provider Name Address, Suite, City, Zip Telephone |
|Date Completed: | / / | |
| |Month/Day/Year | |
| |
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