|
Surgical History
• • •
|
If other, please specify
|
|
Chemotherapy/Radiation Therapy
|
|
|
Family History is Positive/Negative for cancer _
|
in
|
|
Smoking History
|
|
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White/Hispanic
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There is a ____ cm
|
|
nodule/patch
|
on the ______
|
|
It is ____
• • •
|
There is no adenopathy in the bilateral ____
• • •
|
|
Impression
|
|
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goals/risks of radiation treatment explained
|
|
|
The ____
|
__requests to receive the Radiation Therapy
|
|
A consent form was signed by the ___
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|
