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Bladder Cancer

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/Conditions
/Bladder Cancer
/Application Form

Bladder Cancer

Please fill in the form completely.

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Patient Information

Full Name *

Age *

Gender *

What is your complaint?

What are your complaints?

I do not have any

Blood in the urine

Other Complaints

Write your story about your illness.

When did your symptoms start?

Please inform us about the history of your illness:

Your additional diseases:

Previous surgeries (if any):

Please state the medications you take on a regular basis (with doses)

Do you have cancer in your family or close relatives?

If yes, please indicate:

Have you had any previous treatment for this disease?

Did you receive any treatments for this disease before?

I did not receive any treatments for bladder cancer before

Radiation therapy

Drug therapy (Chemotherapy)

Treatment Start Date

Treatment End Date

Radiotherapy Doses You Have Received

Treatment Start Date

Treatment End Date

Treatments You Received

Pathology Reports

Pathology Report of TUR(BT)*

Pathology Report of Re-TUR(BT)

Pathology Report of Cystectomy

Imaging (Radiology) Reports

Urinary Tract Ultrasonography

Complete CT scan of the Abdomen

Thorax (Chest) CT

Complete MRI scan of the Abdomen

Pelvic MRI

Whole Body Bone Scintigraphy

FDG - PET CT

Laboratory Examinations

Hemogram (Complete Blood Count) Report

Biochemistry Report

I have read and understood the Information and Consent Text regarding the Provision of Remote Healthcare Services and hereby accept its terms.*

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