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Lung, neuroendocrine carcinoma in a young woman F /20 (8378) ยป
Form 1
Home
Case
Patient ID
Initials:
Date of birth (dd/mm/yyyy):
Gender:
f
m
Registration date:
Submitting center (city, hospital):
Responsible investigator:
1 History of disease
if yes, specify type and time period:
1.1. Previous diagnosis of MDS:
no
yes
NA
1.2. Preexisting cytopenias > 4 months:
no
yes
NA
1.3. Prior hematological or oncological disease:
no
yes
NA
1.4. Previous exposure to insecticides:
no
yes
NA
1.5. Previous exposure to chemoth. or radioth.:
no
yes
NA
2 Clinical data
2.1. Extramedullary disease:
no
yes
if yes, specify
NA
skin
CNS
lymph nodes, specify:
cervical
thoracic
inguinal
axillary
abdominal
other, specify:
2.2. Splenomegaly:
no
yes
NA
2.3. Hepatomegaly:
no
yes
NA
2.4. Related disorders:
no
yes
NA
Reviewer's assessment:
Comments:
Reviewer:
Last modified:
2009-09-17 13:34:05
