NIH-LRG Virtual GIST Tumor Board Consultation Request Evaluation Form

NIH-LRG Virtual GIST Tumor Board Consultation Request Evaluation Form
All information provided will be kept strictly confidential and is for Virtual Tumor GIST Board only. We are committed to protecting the privacy of those participants. Any data or information that we share in any way is always cleansed of identifying information in order to protect confidentiality.

This form is for the treating physician to fill out. Please fill out this form to the best of your knowledge and circle the appropriate options.

You may mail or fax the completed form to our office at:

NIH-LRG Virtual GIST Tumor Board
c/o The Life Raft Group
155 US Highway 46, Ste. 202
Wayne, NJ 07470
Fax to: (973) 837-9095
E-mail to: dmontoya@liferaftgroup.org

*If you have any immediate needs or questions please call us at
973-837-9092 ext. 114 (9a.m.-5p.m. EST)
All starred (*) sections are required!
Date

MonthDayYear
Date
General Patient Information
Patient's Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
Email*
Back-up E-mail
Date of Birth*
Marital Status

SingleMarriedDivorcedWidowedSeparatedOther
Sex

MaleFemale
Has the patient been to the NIH Clinic in the past?

YesNo
Referring Provider
Doctor*
Specialty
Treating Institution*
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Email*
Clinical History

Diagnosis (Please include the following: imaging studies, pathology studies, molecular studies, mutational analysis)
Date of initial diagnosis*

MonthDayYear
Test Date*

MonthDayYear
C-KIT Results*

PositiveNegativeDon't Know
Date first tumor was found:*

MonthDayYear
Initial Diagnosis*

GISTOther
Initial Diagnosis Comments:
Sites of Disease (localized, metastatic)*
Surgery

If available, please send unstained slides for pathology review and scans for review.
Surgical Procedure Date

MonthDayYear
Outcome
Treatment
Current Therapy Start Date*

MonthDayYear
Medication Name*
Initial Dosage*
Current Dosage*
Reason for altering dosage if changed
Significant Side Effects
Response
Previous Therapy
Previous Therapy Start Date

MonthDayYear
Medication Name
Initial Dosage
Subsequent Dosage
Reason for altering dosage if changed
Significant Side Effects
Reason for discontinuation
Other Medications
Medication Name
Dosage
Add other Medication(s)

yesno
Medication Name
Dosage
Medication Name
Dosage
Current Clinical Dilemmas
What are the questions that we can help answer during this focused meeting?
Should be Empty:

NIH-LRG Virtual GIST Tumor Board Consultation Request Evaluation Form

General Patient Information

Clinical History

Surgery

Treatment

Previous Therapy

Other Medications

Current Clinical Dilemmas