Medical Update Form 6 08 21

Medical Update Form

If you are experiencing a serious or life-threatening emergency, please call 911 or visit the nearest emergency room.
Patient's Name

PrefixFirst NameLast Name
Preferred Method of Contact (if we have follow-up questions)
E-Mail of Person Submitting
Home Phone Number

Country CodeArea CodePhone Number
Mobile Phone Number

Country CodeArea CodePhone Number
Skype ID
WhatsApp Number
Preferred Time of Contact
Evaluation Info (Latest Evaluation)
Would you like to enter an evaluation?
Date of Latest Evaluation

MonthDayYear
Evaluation Type
Pet Scan Results
CT Scan Results
Biopsy Results
MRI Results
Ultrasound Results
Colonoscopy Results
Endoscopy Results
Trough Level (ng/ml)
Mutation Type
Amino Acid
Other Details
Frequency of Evaluation
(ex. every___months)
If your disease progressed, please provide the location where tumor was found.
Other Evaluations
Would you like to enter another evaluation?
Date of Evaluation

MMDDYYYY
Evaluation Type
Pet Scan Results
CT Scan Results
Biopsy Results
MRI Results
Ultrasound Results
Colonoscopy Results
Endoscopy Results
Trough Level (ng/ml)
Mutation Type
Amino Acid
Other Details
Frequency of Evaluation
(ex. every __ months)
If your disease progressed, please provide the location where tumor was found.
Would you like to supply another evaluation?
Date of Evaluation

MMDDYYYY
Evaluation Type
Pet Scan Results
CT Scan Results
Biopsy Results
MRI Results
Ultrasound Results
Colonoscopy Results
Endoscopy Results
Trough Level (ng/ml)
Mutation Type
Amino Acid
Other Details
Frequency of Evaluation
(ex. every __months)
If your disease progressed, please provide the location where the tumor was found.
Treatment Update
Treatment Update
Verify medication name
Verify medication dosage
Dosage
Start Date

MMDDYYYY
End Date

MMDDYYYY
Medication Name
Dosage
Start Date

MMDDYYYY
End Date

MMDDYYYY
Date of latest surgery

MMDDYYYY
Reason for surgery
Did you stop medications prior to surgery?
Treatment stopped on

MMDDYYYY
Treatment restarted on

MMDDYYYY
What treatment(s) did you have prior to your current one?
Date you stopped prior treatment

MMDDYYYY
Other Interventions (i.e. RFA, Emoblization, etc.)
Type of Procedure
Date of latest procedure

MMDDYYYY
Procedure Details / Results
Duration
Days/Weeks (please select one)
Days/Weeks On
Days/Weeks Off
Reason for change
Please provide drug name and manufacturer
Drug name / Manufacturer
Dosage
Start Date

MMDDYYYY
End Date

MMDDYYYY
Are you currently taking the generic form of any oral chemotherapy drug to treat GIST?
If yes, please provide drug name and manufacturer
Drug name / Manufacturer
Dosage
Start Date

MMDDYYYY
End Date

MMDDYYYY
Are you in a Clinical Trial?
If yes, what is Clinical Trial name/drug?
Side Effects Update
Please list your side effects as related to your current drug treatment:
1. Side Effect
Please list one side effect at a time.
What is the location this side effect occurs?
For example: chest, face, head, legs, etc.
Rate the severity of this side effect
Start Date

MMDDYYYY
End Date

MMDDYYYY
Did you experience this side effect prior to your current treatment?
Are you using any form of intervention to manage this side effect?
Please list the interventions you are currently using to cope with this side effect.
Do you want to add another side effect?
2. Side Effect
Please list one side effect at a time.
What is the location this side effect occurs?
For example: chest, face, head, legs, etc.
Rate the severity of this side effect
Start Date

MMDDYYYY
End Date

MMDDYYYY
Did you experience this side effect prior to your current treatment?
Are you using any form of intervention to manage this side effect?
Please list the interventions you are currently using to cope with this side effect.
Do you want to add another side effect?
3. Side Effect
Please list one side effect at a time.
What is the location this side effect occurs?
For example: chest, face, head, legs, etc.
Rate the severity of this side effect
Start Date

MMDDYYYY
End Date

MMDDYYYY
Did you experience this side effect prior to your current treatment?
Are you using any form of intervention to manage this side effect?
Please list the interventions you are currently using to cope with this side effect.
Do you want to add another side effect?
4. Side Effect
Please list one side effect at a time.
What is the location this side effect occurs?
For example: chest, face, head, legs, etc.
Rate the severity of this side effect
Start Date

MMDDYYYY
End Date

MMDDYYYY
Did you experience this side effect prior to your current treatment?
Are you using any form of intervention to manage this side effect?
Please list the interventions you are currently using to cope with this side effect.
Do you want to add another side effect?
5. Side Effect
Please list one side effect at a time.
What is the location this side effect occurs?
For example: chest, face, head, legs, etc.
Rate the severity of this side effect
Start Date

MMDDYYYY
End Date

MMDDYYYY
Did you experience this side effect prior to your current treatment?
Are you using any form of intervention to manage this side effect?
Please list the interventions you are currently using to cope with this side effect.
Do you want to add another side effect?
6. Side Effect
Please list one side effect at a time.
What is the location this side effect occurs?
For example: chest, face, head, legs, etc.
Rate the severity of this side effect
Start Date

MMDDYYYY
End Date

MMDDYYYY
Did you experience this side effect prior to your current treatment?
Are you using any form of intervention to manage this side effect?
Please list the interventions you are currently using to cope with this side effect.
Do you want to add another side effect?
7. Side Effect
Please list one side effect at a time.
What is the location this side effect occurs?
For example: chest, face, head, legs, etc.
Rate the severity of this side effect
Start Date

MMDDYYYY
End Date

MMDDYYYY
Did you experience this side effect prior to your current treatment?
Are you using any form of intervention to manage this side effect?
Please list the interventions you are currently using to cope with this side effect.
Of all the side effects you have listed, which side effect impacts your life the most?
Please use this box for any comments or remarks you want to share with the patient registry staff about your side effects.
Quality of Life Update
Symptoms frequently interfere with how we feel and function. How often have your symptoms interfered with the following items in the last 7 days?

*Why does the Life Raft Group collect this information?
Your ability to take all of your medication as prescribed:
Mood:
Daily household activities:
Relationship with family and friends:
Sleep:
Work:
Eating:
Energy level:
Enjoyment of life:
Participate in the Tissue Bank
Would you like to participate in the Tissue Bank?
Change of Address/Phone/Email Address
Have you moved in the last 12 months?
New Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
New Phone Number

Area CodePhone Number
Do you have a new email address?
New E-mail address
example@example.com
Please note any additional comments or concerns:
Oncologist
Doctor's Name

First NameLast Name
Institution Name
Date you started seeing your doctor

MMDDYYYY
Speciality of Doctor
i.e., primary care, oncology, surgeon, second opinion
Would you recommend this doctor to another GISTer?
Would you like to add another Doctor?
Doctor's Name

First NameLast Name
Institution Name
Speciality of Doctor
i.e., primary care, oncology, surgeon, second opinion
Would you recommend this doctor to another GISTer?
Please verify that you are human
- Should be Empty:

Medical Update Form

Evaluation Info (Latest Evaluation)

Other Evaluations

Treatment Update

Side Effects Update

Quality of Life Update

Participate in the Tissue Bank

Change of Address/Phone/Email Address

Please note any additional comments or concerns:

Oncologist