Formulario Médico Oncológico CATS: Historial y Tratamiento

FORMULÁRIO MÉDICO PARA ABERTURA DE PROCESSOS EM ONCOLOGIA (CÂNCER)
NA CATS (CÂMARA DE AVALIAÇÃO TÉCNICA EM SAÚDE)
Nome do paciente: ___________________________________________________________________________
Idade: _____________Peso:______________ Altura: ____________KPS: ______________________________
CID da doença: _____________Data de início (diagnóstico) da doença:_________________________________
ESTADIAMENTO ATUAL DA DOENÇA
Clínico
I___________ II_________ III_________IV_____________________________________________
TNM
T___________ N__________M________________________________________________________
HISTÓRIA CLÍNICA
(JUSTIFICATIVA PARA A INDICAÇÃO DO MEDICAMENTO/TRATAMENTO SOLICITADO)
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DETALHAMENTO MINUCIOSO DE TRATAMENTO(S) PRÉVIO(S) REALIZADO(S)
CIRURGIA?
Data: ______________________________________________________________________________________
Tipo de cirurgia realizada: _____________________________________________________________________
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RADIOTERAPIA?
Início: _____________________________________________________________________________________
Duração/ciclos: _____________________________________________________________________________
Esquema:___________________________________________________________________________________
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QUIMIOTERAPIA? HORMONIOTERAPIA? OUTROS?
(RELATAR TODOS OS ESQUEMAS REALIZADOS)
 1º Esquema:
Nome do(s) medicamento(s) (esquema):__________________________________________________________
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Data início: _____________________ Data término: _______________________________________________
Ciclos/esquemas realizados: ___________________________________________________________________
Toxicidade/efeitos colaterais:___________________________________________________________________
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Motivo da troca do medicamento:_______________________________________________________________
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 2º Esquema:
Nome do(s) medicamento(s) (esquema):__________________________________________________________
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Data início: _____________________ Data término: _______________________________________________
Ciclos/esquemas realizados: ___________________________________________________________________
Toxicidade/efeitos colaterais:___________________________________________________________________
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Motivo da troca do medicamento:_______________________________________________________________
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 3º Esquema:
Nome do(s) medicamento(s) (esquema):__________________________________________________________
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Data início: _____________________ Data término: _______________________________________________
Ciclos/esquemas realizados:____________________________________________________________________
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Toxicidade/efeitos colaterais:___________________________________________________________________
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Motivo da troca do medicamento: _______________________________________________________________
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DADOS ADICIONAIS
(ALERGIAS, TRATAMENTOS ANTERIORES, OUTRAS INFORMAÇÕES PERTINENTES)
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Data:_________________,___de_______________de_________.
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Assinatura do médico e CRM
Obs.: O relatório médico e a receita médica deverão ser preenchidos de forma legível ou podem ser digitados,
com data inferior a 90 dias, contendo a assinatura e o CRM do médico.