CONFIDENTIAL |
Name and Designation...................................................... |
Hospital.................................................................. |
PLEASE TICK WHICH OF YOUR TEAM MEMBERS (INCLUDING YOURSELF) has a MAJORROLE in providing information to women with breast cancer in each of the following areas.(You may tick more than one box for each area). |
Surgeon | Oncologist | Breast care nurse | Radiologist | Radiographer | Research nurse | Clinic nurse | Ward nurse | Chemo nurse | Other (please state) .................................................... | |
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Diagnostic tests | ||||||||||
Test results/diagnosis | ||||||||||
Surgery | ||||||||||
Prostheses | ||||||||||
Breast reconstruction | ||||||||||
Radiotherapy | ||||||||||
Chemotherapy | ||||||||||
Hormone therapy | ||||||||||
Prognosis | ||||||||||
Staging investigations | ||||||||||
Clinical trials | ||||||||||
Family history | ||||||||||
Information leaflets |