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 :
Secondary loco-regional or distant metastatic site
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