OncoxAI Clinical Case Review – Required Information Form

OncoxAI Clinical Case Review – Required Information Form
Patient age*
MaleFemaleN/A
Country of treatment*
Current performance status (if known – ECOG/Karnofsky)
Primary treating institution
Cancer type*
Primary tumor location*
Histological subtype
Stage at diagnosis
Current stage (if different)
Date of initial diagnosis*

MonthDayYear
Date
Molecular or genetic findings (if available)
Treatment type*
Treatment name*
Treatment start date

MonthDayYear
Date
Treatment end date

MonthDayYear
Date
Treatment intent
Response (if known)
Reason for discontinuation
Type of surgery
Surgery date

MonthDayYear
Date
Margin status
Lymph node involvement
Postoperative complications (if relevant)
Radiation site
Total dose (Gy)
Fractionation
Radiation start date

MonthDayYear
Date
Radiation end date

MonthDayYear
Date
Organs exposed (if known)
Re-irradiation history
Drug names
Number of cycles
Complete responsePartial responseStable diseaseProgression
Known active disease locations
Metastatic sites
Most recent imaging date

MonthDayYear
Date
Current symptoms
Required documents

Cancelof
Optional documents

Cancelof
Kidney function issuesLiver limitationsPrior radiation limitsCardiac riskTreatment toxicities experiencedOther
What question would you like this review to help clarify?*
Treating specialty
Institution
Contact
Disease controlQuality of lifeRisk understandingTreatment optionsSecond perspective
Consent*
Should be Empty: