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Liver Cancer

Home
/Conditions
/Liver Cancer
/Application Form

Liver 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

Abdominal Pain

Jaundice

Weight Loss

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 a first or second degree relative with colorectal cancer?

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 liver and biliary tract cancers 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

Needle Biopsy Report

Endoscopic Biopsy Report

Pathology Report of the Liver / Biliary Tract Cancer Surgery if Performed

Endoscopy Reports

Gastroscopy Report

Colonoscopy Report

Imaging (Radiology) Reports

Thorax (Chest) X-ray

Standing Direct Radiography of the Abdomen

Complete Ultrasonography of the Abdomen

Complete CT scan of the Abdomen

Complete MRI scan of the Abdomen

ERCP

MRI - ERCP

Thorax (Chest) CT

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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