Dear Patient,

In order to assess your status and give you the quality-wise best possible advise,
please answer the following questions before coming to see us:

Patient
Name:
Male
Date of Birth:
Currently living in:

Patient Status
I lead (please tick, as appropriate)
o a normal life
o suffer from life restrictions, please specify
o am able to travel
o am bed ridden

Diagnosis
Diagnosis:
Primary diagnosis made on (month / year):
Primary histologic diagnosis (please give summary of histologic report, cut and
paste):

Metastases
o no
o diagnosed on (month / year):

Currently cancer-involved organs (please tick as appropriate)

o lymph nodes
o brain
o lungs
o liver
o adrenal glands
o bones
o peritoneum
o pleura
o soft tissue
o other (please specify):

Organ involvement diagnosed by (please tick, as appropriate)

o CT, date (month / year):
o Magnetic Resonance, date (month / year):
o PET-CT, date (month / year):
o Biopsy, date (month / year):

Treatment History
please give a description of the treatments (only drug names!) you have received
including dates (month / year, from / until):