Cancer/Terminal Diagnosis Fact Sheet


Dear Physician:

Please complete this form as completely as possible.  It is an important part of the admission
documentation to the Kresge Residence.  

Thank you very much for your help and information.  Please page me at 448-8697 if for some
reason this information is not available or if you have any questions.

Sincerely,

Robert S. Stall, M.D.
Medical Director
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Please return in the enclosed stamped, self-addressed envelope.  If you have any questions, please
contact Robert S. Stall, M.D. at 448-8697, or by contacting the office at 686-8050.

Patient's name:                                                  
Physician:                                                       

1.   What cancer/terminal disease does your patient have?  Are there any metastases?
                   (Please circle all that apply)

Brain/Breast/Colon/Esophageal/Laryngeal/Lung/Pancreatic/Prostate Cancer/Other (specify):
                                  
Noninvasive/Local Invasion/Local Nodes Involved/Distant Nodes Involved/Distant Mets
                                  
Bone/Brain/Liver/Lung Mets/Other (specify):

2.   What is the estimated life expectancy if untreated (circle best estimate)?

     <1 week   1 month   3 months  6months   1 year    >1 year

3.   What treatment options remain (circle all that apply)?

     Chemotherapy   Radiation Surgical Resection       Palliative Care Only 

4.   Is any further treatment planned?

                    Yes       No

5.   If not, does the patient/family (if patient lacks capacity) fully understand the treatment
options and prognosis if untreated?

                    Yes       No

6.   Additional Comments:



Physician signature:                                Date:        

termdxck.frm 12/12/98   Robert S. Stall, M.D.