Mental Health Study Chart Audit Form Page 3
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MENTAL HEALTH STUDY CHART AUDIT FORM
Current Symptoms:
Pain
_____
Urinary Incontinence
_____
Fatigue
_____
Bowel Incontinence
_____
Nausea
_____
Urinary Symptoms
_____
(dyusria, frequency hematuria)
Vomiting
_____
Appetite
_____
GI Mucosal
_____
Constipation
_____
Hot Flashes
_____
Diarrhea
_____
Impotence
_____
Mobility
_____
Respiratory
_____
Infection
_____
Coping
_____
Other
__________________________________________________
Current treatment for prostate cancer:
Check
only ONE answer below that best describes the patient’s CURRENT TREATMENT or purpose
of his appointment today.
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Observation
2
Hormone Therapy
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Chemotherapy
4
Radiation for relief of symptoms (<10 fractions @ < 6,000 cGy)
5
Pain and symptom management
6
Other
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