Prostate Onco Study Performa
Was the informed consent signed by patient:
Yes
No
Attach Scanned Form:
Date of Singnature:
Name
Hospital Record ID(File No.):
Date of Birth:
Gender:
Male
Female
Address
Hospital Name:
Phone No:
Phone No. 2:
Date Of Diagnosis:
CNIC
Height (cm)
Weight(kg)
ECOG/WHO Score:
0-Symptomatic
1-Symptomatic but completely ambulatory
2-Symptomatic, less then 50%in bed during the day
3-Symptomatic greater then50% in bed but not bedbound
4-Bedbound
5-Dead
N/A
Comorbidities:
Yes
No
if yes please specify:
Neurological disorder
Cardiovascular disorder
Hypertension
Diabetes
Chronic liver disease
Chronic renal disease
Behavior disorder
Other:
PSA on diagnosis:
H/o Prior Prostate Surgery:
Yes
No
N/A
Date:
In case of prior Prostate Surgery:
Risk Group:
Grade Group
Gleason Score
Gleason Pattern
HISTOPATHOLOGY:
Adenocarcinoma
Adeno with NEC differentiation
Prior Radiation :
Yes
No
Unknown
Prior Radiation Date:
Orchiectomy:
Yes
No
Unknown
Orchiectomy Date:
-
LHRH analogue use
Yes
No
Agent
Dose
From(Date)
Till(Date)
Family History of malignancy
Yes
No
Unknown
Known genetic mutation :
Castration
Resistant
Sensitive
Metastasis site:
Nodal
Bone
Less than 3
Greater than 3
Visceral:
Liver
Lung
Other:
History of receiving bone protecting agents:
Zolendronic Acid
Denosumab
Other:
Previous Treatment agents:
Enzalutamide/Daralutamide/Aplutamide
Docetaxel
Casodex
Treatment Abityga (Abiraterone)
Abiraterone:
Dose
Start Date
End Date
Dose Modification
Reason for Modification
PSA Response
Side effect Profile :
Side Effects :
Hypertension
Grade (I-IV):
Management:
Hyperglycemia
Grade (I-IV):
Management:
Electrolyte imbalances
Grade (I-IV):
Management:
Hepatotoxicity
Grade (I-IV):
Management:
Fatigue
Grade (I-IV):
Management:
Fluid retention
Grade (I-IV):
Management:
Anemia
Grade (I-IV):
Management:
Any Others:
Grade (I-IV):
Management:
Next Line Recommended:
TTP Time in months
Clinical progression
Radiological progression
PSA progression
PSA doubling time in months on Abiraterone
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Institute/Organization:
Supervised by:
Supervisor's Name:
Supervisor's Email:
Supervisor's Phone No:
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