Report 2003 - Lebanese Cancer Society

(2) Identification Number
□□□□□□□□□□□
□
□
(7) PRIMARY SITE (text)
(10) PATHOLOGY (text)
( 4)
ﺮآذ
ﻰﺜﻧأ
NATIONAL TUMOR REGISTRY
PATIENT INFORMATION
ﺔﻠﺋﺎﻌﻟا ﻢﺳا مﻷا ﻢﺳا بﻻا ﻢﺳا ﺾﻳﺮﻤﻟا ﻢﺳا (1)
43
( ءﺎﺴﻨﻠﻟ)
جاوﺰﻟا ﻞﺒﻗ ﺔﻠﺋﺎﻌﻟا ﻢﺳا
--------------------------/
----------------/
------------------- : دﻼﻴﻤﻟا ﺦﻳرﺎﺗ ( 3)
مﻮﻳ ﺮﻬﺷ ﺔﻨﺳ
----------------------ءﺎﻀﻗ---------------------------
ﺔﻳﺮﻘﻟا / ﺔﻨﻳﺪﻤﻟا : ةدﻻﻮﻟا نﺎﻜﻣ
------------------------ءﺎﻀﻗ
-------------------------ﺪﻠﺑ
------ ﺪﻠﺑ
---------------------------ﺔﻈﻓﺎﺤﻣ
---------------------ﺔﻳﺮﻘﻟا
/ ﺔﻨﻳﺪﻤﻟا : ﻢﺋاﺪﻟا ﺔﻣﺎﻗﻹا ناﻮﻨﻋ ( 5)
-- ---------------------------ﺔﻈﻓﺎﺤﻣ
TUMOR INFORMATION
(8) TOPOGRAPHY (right, left, anterior, etc..)
(11) ICD - O
□ □ □ □ /□
: نﻮﻔﻠﺘﻟا ﻢﻗر ( 6)
(9) ICD 10
□ □ □ ● □
(12) DATE OF DIAGNOSIS
□□/□□/□□□□
D M Y
(13) TNM COMPONENTS T □ N □ M □ OR STAGE I □a / b II□ a / b III□ a / b IV□ a / b
(14) FINALITY OF INITIAL
TREATMENT
Curative □ Palliative □
(17) TREATING PHYSICIANS
(18) PATHOLOGY CENTER
TREATMENT INFORMATION
(15) TYPES OF TREATMENT (all that
apply)
Surgery □ Chemotherapy □
Radiotherapy □ Immunotherapy □
(16) FOR FOLLOWING
VISITS
Relapse □
Remission □
(19) SIGNATURE AND NAME OF PHYSICIAN WHO COMPLETED THIS FORM
Date:____/______/______
Serial Number ( for administration only):……………………..