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Contact Us About Your Specific Case

Please spend a few moments telling us about your specific liver cancer case so that we can provide a thorough response. (All fields are required)

BACKGROUND INFORMATION
What is the purpose of your inquiry? (In a few sentences, tell us why you are writing us. Please be as specific as possible):
DIAGNOSIS AND TREATMENT
Name of Patient:
Age of Patient
When was the patient diagnosed?
Diagnosis Information: Hepatitis Cirrhosis Hepatoma Colon Cancer Breast Cancer Lung Cancer Other form of cancer:
How has the physician described the problem in the liver? Please describe: (Be briefly specific)
What treatments has the patient undergone? Surgery Chemotherapy - 5FU Chemotherapy - Leukovorin Radiation Other (please explain):
Describe any treatments that the patient is currently receiving:
CURRENT STATUS
Has the patient experienced weight loss? 10 lbs. or less 10-25 lbs. 25-40 over 40 lbs.
Is the patient jaundiced? Yes No
Check the item that best describes the patient's current condition: Normal, no complaints, no external evidence of disease Able to carry on normal activity, minor signs or symptoms of disease Normal activity with effort, some signs of symptoms of disease Able to care for self, unable to carry on normal activity or to do work Requires occasional assistance from others; frequent medical care Requires considerable assistance from others; frequent medical care Disabled, requires special care and assistance Severely disabled, hospitalization indicated
Is the patient eating normally? Yes No
PLEASE PROVIDE CONTACT INFORMATION
First Name:	Last Name:
Address:
Zip Code:
Phone:	EMail:
Additional Comments: