- 肺癌疫苗需要填写的英文表格
- 作者：孙希文|发布时间：2012-05-23|浏览量：718次
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ANAMNESIS - CIMAvax ? EGF上海市肺科医院影像科孙希文 |
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Date: |__|__|/|__|__|/|__|__|__|__| |
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1. Patient initials |__|_ _|_ _|_ | |
2. Age |__|__|(Years) |
3. Sex M F |
4. Performance Status: Karnofsky: |_____| ECOG:|_____| |
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5. Doctor Name: |
6. Specialty: |
7. Professional Code.: |
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8. Department: |
9. Hospital |
10. Address: |
11. Phone |
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12. Diagnostic: NSCLC Other Specify _____________________________________ |
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13. Histologic Type: Adenocarcinoma: Epidermoid: Other Specify: _______________________________________ |
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DATOS DE LA ENFERMEDAD |
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14. Primary tumour Yes No |
15. Primary tumour, diagnostic date |__| |__|/|__|__|/|__|__|__|__| dd/mm/yyyy Preferible, confirmation date from patologic histology |
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16. Localización anatómica: |
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17. Metastasis Yes No |
18 Metastasis and/or Recidival, date |__|__|/|__|__|/|__|_|__|__|| dd/mm/yyyy |
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19. Metastasis localization (s):
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20. Clasification T|__| N|_ _| M|__| NC |__| NC: Non clasificable |
21. Stage I II III IV NC
NC: Non clasificable |
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22. Previous treatments received: Yes No
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23. Surgery Yes No |
24. Quimiotherapy Describe
___________________ ___________________ |
25. Other therapy Specify ______________ Yes No ______________ ______________ |
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26. Radioterapy Yes No |
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COMORBILITY: |
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ACTUAL STATUS: |
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27. Completa Resolution (CR): |
28. Partial Resolution (PR): |
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29. Stable Status, Non Progression (SS): |
30. In progress: |
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CIMAvax-EGF, TREATMENT PROPOSE: |
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Combination with Quimiotherapy (Q/V) : |
Combination with Radiotherapy: |
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Combination with Quimiotherapy (V/Q/V) |
Monotherapy: |
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Combination with others onco therapies. |
Describe: |
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