NIH-LRG Virtual GIST Tumor Board Consultation Request Evaluation Form

NIH-LRG Virtual GIST Tumor Board Consultation Request Evaluation Form
All information provided will be kept strictly confidential and is for Virtual Tumor GIST Board only. We are committed to protecting the privacy of those participants. Any data or information that we share in any way is always cleansed of identifying information in order to protect confidentiality.

This form is for the treating physician to fill out. Please fill out this form to the best of your knowledge and circle the appropriate options.

You may mail or fax the completed form to our office at:

NIH-LRG Virtual GIST Tumor Board
c/o The Life Raft Group
155 US Highway 46, Ste. 202
Wayne, NJ 07470
Fax to: (973) 837-9095
E-mail to: dmontoya@liferaftgroup.org

*If you have any immediate needs or questions please call us at
973-837-9092 ext. 114 (9a.m.-5p.m. EST)
All starred (*) sections are required!
General Patient Information
Patient's Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Fax Number

Area Code Phone Number
Email *
Back-up E-mail
Date of Birth *
Marital Status

Single Married Divorced Widowed Separated
Sex

Male Female
Has the patient been to the NIH Clinic in the past?

Yes No
Referring Provider
Doctor *
Specialty
Treating Institution *
Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Email *
Clinical History

Diagnosis (Please include the following: imaging studies, pathology studies, molecular studies, mutational analysis)
Date of initial diagnosis *

Month Day Year
Test Date *

Month Day Year
C-KIT Results *

Positive Negative Don't Know
Date first tumor was found: *

Month Day Year
Initial Diagnosis *

GIST
Initial Diagnosis Comments:
Sites of Disease (localized, metastatic) *
Surgery

If available, please send unstained slides for pathology review and scans for review.
Surgical Procedure Date

Month Day Year
Outcome
Treatment
Current Therapy Start Date *

Month Day Year
Medication Name *
Initial Dosage *
Current Dosage *
Reason for altering dosage if changed
Significant Side Effects
Response
Previous Therapy
Previous Therapy Start Date

Month Day Year
Medication Name
Initial Dosage
Subsequent Dosage
Reason for altering dosage if changed
Significant Side Effects
Reason for discontinuation
Other Medications
Medication Name
Dosage
Add other Medication(s)

yes no
Medication Name
Dosage
Medication Name
Dosage
Current Clinical Dilemmas
What are the questions that we can help answer during this focused meeting?
Should be Empty:

NIH-LRG Virtual GIST Tumor Board Consultation Request Evaluation Form

General Patient Information

Clinical History

Surgery

Treatment

Previous Therapy

Other Medications

Current Clinical Dilemmas