259
MENTAL HEALTH STUDY CHART AUDIT FORM
Prostate Cancer: Mental Health Study Chart Audit Form
Patient’s Initials:
Study ID #:________________Date:___ /___ /_____
dd mm yyyy
DEMOGRAPHIC DATA SHEET
Name: _______________________________________________________________________________
First
Last
Address:
________________________________________________________________________
Street Address
________________________________________________________________________
City
Province
Postal Code
Birthdate::
___ /
dd
___ /
mm
_____
yyyy
Date of diagnosis of prostate cancer:
OCTRF No.:
___ /
dd
___ /
mm
_____-_______________
_____
yyyy
Time since diagnosis of prostate cancer ( check one):
1
2
3
4
5
6
7
< 3 months
3 months but < 1 year
1 year but < 2 years
2 years but < 5 years
5 years but < 6 years
6 years but < 10 years
10 or more years
Stage at Diagnosis:
1
2
3
4
5
___/___/___
TMN
___/___/___
AUS
0
I
II
III
IV
Stage as recorded in patient file:
Hemoglobin level: __ __ __ __ g/L
Date:
PSA level: __ __ , __ __ __ . __ __ ug/mL
___/___/______ (+/- 2 weeks of appt.)
dd mm yyyy
Date:
___/___/______
260
MENTAL HEALTH STUDY CHART AUDIT FORM
Patient’s Current Stage of Advanced Disease (check only one):
D1: Pelvic lymph node metastasis or ureteral obstruction causing hydronephrosis or both ____
D2: Bone, soft tissue, organ, or distant lymph node metatstasis _____
Patient’s Current Disease Status (check only one):
1)
Hormone Sensitive: stable PSA < 1.0 on hormone suppression therapy ____
(may have new diagnosis of advanced prostate cancer or recurrent disease following previous
treatment for early stage disease)
2) Hormone Refractory: ____
Meets these criteria:
a) 3 progressive rises in PSA following a response to androgen suppression therapy
Date 1: ________ PSA = ______ ug/L
Date 2: ________
PSA = ______ ug/L
Date 3: ________
PSA = ______ ug/L
b) Asymptomatic, stable symptoms, or symptoms responsive to treatment
c)
Has not required mitoxontrone chemotherapy
3) Hormone Refractory Receiving Palliative Care: ______
Meets all these criteria:
a)
Hormone Refractory as above with continued rise in PSA
Date 1: ________ PSA = ______ ug/L
Date 2: ________
PSA = ______ ug/L
Date 3: ________
PSA = ______ ug/L
b) New symptoms and/or progressive symptoms such as pain, fatigue, weight loss, or nausea
c)
Completed course of mitoxantrone chemo, or was not eligible to receive mitoxontrone
because of cardiac status
d) Requiring aggressive pain and symptom management such as: escalating analgesia, steroids,
palliative radiation, strontium
261
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.
1
2
3
4
5
6
Observation
Hormone Therapy
Chemotherapy
Radiation for relief of symptoms (<10 fractions @ < 6,000 cGy)
Pain and symptom management
Other
262
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
2
3
4
5
6
7
8
9
10
11
12
13
Assessment, tests results, and/or treatment information for a NEW diagnosis of prostate cancer.
Observation or followup of treatment
Radical prostatectomy
Curative radiation therapy only to prostate gland (30-35 Tx @ >6,000 cGy)
Iridium implant
Hormone therapy only
Curative radiation therapy and hormone therapy combined
Orchidectomy (removal of testicles)
Chemotherapy
Radiation for relief of symptoms (<10 Tx @ < 6,000 rads)
Pain and symptom management
Other (please describe) _____________________________________________________
None
Reason for ineligibility (check only one):
1
2
3
4
5
6
Patient too ill
Not able to enroll patient in study
Language barrier
Patient mentally incapable
Other, please specify: ______________________________________________________
Patient refused
Marital Status (check only one):
1
2
3
4
5
Married/Cohabitating
Single
Divorced
Widowed
Data Unavailable
Postal Code:
_________________________
Living Arrangement:
1
2
3
Living with Spouse/Significant Other/Family
Living Alone
Data Unavailable