Identification NO.

Head & Neck Cancer Data Entry Form & Summary

Otorhinolaryngology, Head & Neck Surgery Department
Cornwall Regional Hospital (W.R.H.A)
Date:dd/mm/yy Consultations/Referrals: Radiotherapy Haematology/oncology Nutritionist Dental General Surgery other
Section I. Demographic Data
Last Name: First Name: Date of Birth (D.O.B): Docket Number:
dd/mm/yy -- --
Source of Information: Gender: Male Female Address:
Parish:
Contact Information: Patient’s Occupation: Unemployed
Race/Ethnicity(descent): Black/Afro-Caribbean Asian-Indian Asian-Chinese/Japanese White Hispanic Mixed Other__________
Section II. Historical Data, Physical Findings & Investigations
Chief or Main Presenting Complaint: Comorbidities: Diabetes Mellitus Hypertension Cardiac disease
Duration: Asthma COPD Arthritis Liver disease Renal disease
Associated Symptoms: Asymptomatic Non-specific (constitutional) symptoms: Un-intentional weight loss
sweating fever lethargy malaise other____________
Throat: hoarseness Sore throat dysphagia haemoptysis Otologic: otalgia hearing loss vertigo
neck lump(s) painless painful globus sensation tinnitus otorrhea
trismus halitosis odynophagia persistent cough
Nasal epistaxis rhinorrhea facial swelling facial pain Ophthalmological: decreased visual acuity
post nasal drip sneezing nasal congestion anosmia proptosis diplopia ptosis
Other Relevant Previous ENT, H&N cancer diagnosis Family History of Cancer? yes no
History: Previous non-ENT cancer diagnosis Type(s):
*Histopathology: ________________________________________ Relationship:
Possible associated risk factors|| Smoking Cigarettes Marijuana ||Duration of smoking_____| Alcohol ___bottles per week |Other:
Physical Examination Findings of the Head & Neck region
*Inspection: Ill-looking Respiratory distress/Stridor Cachexia suspicious skin lesion facial swelling
*Neck Mass/Lump: Thyroid Pre-auricular Submandibular Lymphadenopathy Level. 1 2a 2b 3 4 5a 5b 6 *
*Rhinoscopy: Nasal cavity lesion/polyp blood * Cranial nerve deficits ____* *Otoscopy: Serous Otitis media Ear canal lesion
Oral cavity &Oropharynx: poor dentition, salivary pooling, *Lesion or ulcer: Tonsil floor of mouth gingiva, hard palate, lateral tongue
border, Tongue base retromolar trigone Lateral oropharyngeal wall
Fibre-optic Endoscopy: *Lesion seen in/on the: vocal cord(s) supra-glottis trans-glottic VC paralysis Piriform fossa Nasopharyngeal recess
Other physical findings:
Radiologic tests requested: CXR Neck Ultrasound CT Neck/Chest M.R.I Other please specify_____________________________
-Positive findings-
Clinical (ICD-10 coding): Unknown Primary
Diagnosis
Section III. Pathology: Cytology/Histopathology Results
FNAC: Excisional/Incisional biopsy: Immunohistochemistry:
C.R.N#& Date: C.R.N#: & Date: HPV: Positive Negative Not requested
Final Histopathological Diagnosis & Stage: A.J.C.C 8th edition: T___N___M___
ICD-10 coding):
Section IV. Modalities of Treatment Chosen & Complications
Surgery only Surgical operations or procedures done: List any perioperative complications: airway compromise
Chemotherapy only 1. vascular injury nerve injury Infection haematoma
Radiotherapy only 2. fistula flap complications ophthalmologic endocrine
Surgery & Post-op RT Interval between diagnosis & Surgery: Other:
chemo-radiotherapy Dosage & duration of RT: Start date: List any Post Radiotherapy complaints: xerostomia
Still awaiting further dermatitis lymphedema, tooth decay hypothyroidism
therapy (Chemo/Radiotherapy) Interval between diagnosis & starting End date Other:
Patient declined above RT:
treatment options List any Post Chemotherapy complaints/complications:
other, please specify Chemotherapy regime & dosages: Start date: Alopecia nausea/vomiting loss of appetite Infection
______________________ Easy bruising or bleeding anaemia
End date: Other:
Section V. Outcome, & Expected Prognosis
Expected Favourable Poor Patient received Long term tracheostomy At the time of completing this form, the patient is/was:
Prognosis: Unknown /not sure pain medication gastrostomy Alive Deceased Status Unknown

Period of research: ________to_________ Form Officially Reviewed by: __________________________

(Name & Signature) Date: dd/mm/yy