Mental Health Study Chart Audit Form Page 4
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MENTAL HEALTH STUDY CHART AUDIT FORM
Previous treatment for prostate cancer:
Check
ALL of the PREVIOUS TREATMENTS the patient has had for his prostate cancer. Do not
include the current treatment checked above.
1
Assessment, tests results, and/or treatment information for a NEW diagnosis of prostate cancer.
2
Observation or followup of treatment
3
Radical prostatectomy
4
Curative radiation therapy only to prostate gland (30-35 Tx @ >6,000 cGy)
5
Iridium implant
6
Hormone therapy only
7
Curative radiation therapy and hormone therapy combined
8
Orchidectomy (removal of testicles)
9
Chemotherapy
10
Radiation for relief of symptoms (<10 Tx @ < 6,000 rads)
11
Pain and symptom management
12
Other (please describe) _____________________________________________________
13
None
Reason for ineligibility (check
only one):
1
Patient too ill
2
Not able to enroll patient in study
3
Language barrier
4
Patient mentally incapable
5
Other, please specify: ______________________________________________________
6
Patient refused
Marital Status (check
only one):
1
Married/Cohabitating
2
Single
3
Divorced
4
Widowed
5
Data Unavailable
Postal Code:
_________________________
Living Arrangement:
1
Living with Spouse/Significant Other/Family
2
Living Alone
3
Data Unavailable
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