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Alternative Form option (PDF)

Lung MDT Assessment Form

(Information with red asterisk ( *) must be supplied)

PRESENTING CLINICIAN

REVIEW AT MEETING

TRIAGE CATEGORY

PATIENT PRESENTING SYMPTOMS

Greater or equal to 10%      
Less than 10%     
None     
0      1      2      3      4     
Never     
Ex     
Current     
Yes      No     
Yes      No     
Yes      No     
Yes      No     
Yes      No     

PATHOLOGY AND STAGING

Yes      No     

CLINICAL STAGE

PET STAGE

PATHOLOGICAL STAGE

INVESTIGATIONS

Yes      No     
Yes      No     
Yes      No     
Yes      No     
Yes      No     
Yes      No     
Yes      No     
Yes      No     
Yes      No     

PREVIOUS TREATMENTS FOR LUNG CANCER - CURRENT OR RECURRENT

Yes      No     
Yes      No     

 

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Page last updated: 28 April, 2020