Primary Cancer site :
  • Cancer of the lung, non-small cell type
  • Cancer of the lung, small cell type
  • Malignant sarcoma
  • Head and neck cancer
  • Cancer of the rectum
  • Cancer of the stomach
  • Cancer of the breast
  • Cancer of the cervix
  • Cancer of the bladder
  • Malignant lymphoma
  • Cancer of the colon
  • Other primary cancer site
Dominant (or potentially life threatening) loco-regional or distant metastatic site :
  • Lung
  • Bone
  • Liver
  • Central nervous system
  • Pleura
  • Chest wall
  • Lymph nodes
  • Other
  • Secondary loco-regional or distant metastatic site
  • Lung
  • Bone
  • Liver
  • Central nervous system
  • Pleura
  • Chest wall
  • Lymph nodes
  • Other
  • Chronic obstructive pulmonary disease

    Yes/None

    Cardiac disease

    Hypertension : Yes/None

    Ischemic heart disease : Yes/None

    Valvular heart disease : Yes/None

    Cardiomyopathy, type uncertain : Yes/None

    Other type : Yes/None

    Cerebrovascular disease

    Yes/None

    Diabetes mellitus

    Yes/None

    Any medication with allergic or major adverse reactions

    Yes Name:

    None

    Details of common symptoms which the patient acknowledges

    Bone pain : Yes/None

    Major pain site:

    Recent Development of acute pain with score of 6 or greater Yes/None

    Wheezing : Yes/None

    Productive cough : Yes/None

    Chest wall/pleural discomfort/pain : Yes / No

    if yes : Right Side Left Side

    Patient’s major health concern