Cancer Clinic Tijuana / Dr. Salvador Vargas

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General information:

Patient Last Name

Patient First Name

Gender *

Phone *

Email *

Address

Street Address

City

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Country

Postal Code

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Original diagnosis, classification, Stage:

Date of original diagnosis

Previous treatment received:

Surgery (Date)

Chemotherapy (Agents and dates)

Radiation (dose, site and date)

Hormone therapy (agents and dates)

Others (types and dates)

Results and side effects from any of the above

Present situation of your disease, stage, complications, symptoms

Resent Interventions

Current treatments/medications

Most recent laboratory report (attach if available)

Most recent imaging study reports (attach if available)

Present status performance (ECOG or Karnofsky score)

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