ALLINDA NSIIIUTE OF MEDICAL SCIENCES, PATNA

DEPARTMENT OFMEDICAL ONCOLOGY/HAMATOLOGY

PATIENT EALUATION PORM-SOLD TUMOUR ONCOLOGY

Name Age Ser CBC

2
Seroo
Co-morbidties 10 RT
LLT,
Drags history Sod, Pot
OtherTNR
3 Cafer Compbfuts/ROFL y/CTscan(pe-trextmeat)

Date

Past mdieu lreatsoat hitery MRIPHETCT (pire trestnn)

PerforaaNCe statas (ECOG) Bone scan/ 24D ECHO

Date
6
EXAMHNATRONNDINGS
Generaiârminafiaa/ Vitais
14
FNACCytology
Date

Heieht Weght BSA

Cardiovascelar/ Respiratory/ Bipsy

AbdomiaNeuralogicai
Date

Hesd Neci/ Lynh nodes/Breast

Gyzaecslagy/ PR ete FRao0-5iatoehemisiy
Dafe

17 0ther Ltyestsations
Date

18 Fa! Degsk
TREAMNTLAN
Stage

Rik Soorestrteatio