New Jersey Department of Health

Cancer Epidemiology Services

P.O. Box 369, Trenton, NJ 08625-0369

Telephone Number (609) 633-0500 / Fax Number (609) 633-7509

HEMATOLOGY/ONCOLOGY PHYSICIAN REPORT (09700)	FOR OFFICE USE ONLY
CTR #:	______________
Practice Name:
Physician Name:
Street Address:
City, State, Zip Code:
Telephone / Fax:
Patient Name
Date of Birth
Social Security Number
Patient Address
Race/Ethnicity
Marital Status
Sex
City, State, Zip Code
Occupation
Industry
Primary Site/Laterality of this cancer (attach pathology report):
Histology Type of this cancer:
Date this cancer was FIRST DIAGNOSED:	/ /
Month/Day/Year
Initial visit for this cancer:	/ /
Most recent visit for this cancer:	/ /
Month/Day/Year
Month/Day/Year
STAGE INFORMATION (Please refer to AJCC Cancer Staging Manual.)
Primary Tumor (T)	Regional Lymph Nodes(N)	Distant Metastases (M)
Tumor Size:	Systemic Symptoms at Dx:	IPI Score
Stage @ Diagnosis:	Lymph Node Status @ Dx:
Tumor Markers:
Name
Results
Did this patient receive any treatment for this cancer?	Yes No	If “Yes,” please complete the following:
Active Surveillance/watchful waiting?	Yes No
/	/
Surgery (specify type)
Month	Day	Year
/	/
Chemotherapy (specify agents, amount, duration)
Month	Day	Year
/	/
Radiation Therapy (specify amount, method, duration)
Month	Day	Year
/	/
Immunotherapy (specify type, duration)
Month	Day	Year
/	/
Hematologic Transplant and Endocrine Procedures
Month	Day	Year
/	/
Hormone/Other Treatment (specify type, amount, duration)
Month	Day	Year
Referred to Physician/Hospital:
Provider Name	Address, Suite, City, Zip	Telephone
Date Completed:	/ /
Month/Day/Year

CES-12

AUG 13	USE BACK OF FORM FOR ADDITIONAL COMMENTS

CES-12, Hematology/Oncology Physician Report

CES-12, Physician Report, hematology, oncology, cancer epidemiology, CES

EWhite

2012-03-20

NJDOH