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) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ DETALHAMENTO MINUCIOSO DE TRATAMENTO(S) PRÉVIO(S) REALIZADO(S) CIRURGIA? Data: ______________________________________________________________________________________ Tipo de cirurgia realizada: _____________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ RADIOTERAPIA? Início: _____________________________________________________________________________________ Duração/ciclos: _____________________________________________________________________________ Esquema:___________________________________________________________________________________ __________________________________________________________________________________________ QUIMIOTERAPIA? HORMONIOTERAPIA? OUTROS? (RELATAR TODOS OS ESQUEMAS REALIZADOS) 1º Esquema: Nome do(s) medicamento(s) (esquema):__________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Data início: _____________________ Data término: _______________________________________________ Ciclos/esquemas realizados: ___________________________________________________________________ Toxicidade/efeitos colaterais:___________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Motivo da troca do medicamento:_______________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 2º Esquema: Nome do(s) medicamento(s) (esquema):__________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Data início: _____________________ Data término: _______________________________________________ Ciclos/esquemas realizados: ___________________________________________________________________ Toxicidade/efeitos colaterais:___________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Motivo da troca do medicamento:_______________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 3º Esquema: Nome do(s) medicamento(s) (esquema):__________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Data início: _____________________ Data término: _______________________________________________ Ciclos/esquemas realizados:____________________________________________________________________ __________________________________________________________________________________________ Toxicidade/efeitos colaterais:___________________________________________________________________ __________________________________________________________________________________________ Motivo da troca do medicamento: _______________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ DADOS ADICIONAIS (ALERGIAS, TRATAMENTOS ANTERIORES, OUTRAS INFORMAÇÕES PERTINENTES) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Data:_________________,___de_______________de_________. ________________________________________________ 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.