ELDORET CANCER REGISTRY FORM.pdf - THE ELDORET CANCER REGISTRY CANCER NOTIFICATION FORM Cancer registry Number 1 PATIENT(First name(s Given name

ELDORET CANCER REGISTRY FORM.pdf - THE ELDORET CANCER...

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THE ELDORET CANCER REGISTRY CANCER NOTIFICATION FORM (First name(s) ……….…………………… .................. ...... Given name …….…………………… ............................ Surname (Family name) ................................................................... I.D. Number: ................................... Date of birth Age: Sex: (1=male, 2=female, 9=NK) Place of birth …………………………………………………………………………………………………………………….. Usual residence address: …………………………………………………………………………………………………………... Concurrent illness…………………………………………………… (1=Positive, 2=Negative, 9=NK) Next of Kin: Father/Mother/Husband/Wife/Son/Daughter ……………………………………………………………. Patients Tele. number: Tel No. Next of Kin Ethnic group: Death Certificate No. 2. FOLLOW UP Date of last contact (dd/mm/yyyy): Status at last contact (1=Alive, 2=Dead, 9=NK) ____________ Hospice No. _______________________________________ Cause of death (1= this cancer, 2= 0ther cause, 9= NK) Patients Age ……………………… Address Code ……………………………………………………………………………….……….
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  • Winter '16
  • Marie Troya
  • Management, ........., Cancer staging, lymph node

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