Surname: | DOB: | |
Forename(s): | Gender: | |
CHI: | ||
Occupation: | Ethnicity: | |
Date of primary melanoma diagnosis: | ||
Melanoma type: | ||
Stage of melanoma: | ||
Tumour thickness (mm): | Breslow depth; | |
Clark level; | ||
Prognostic features: | Ulceration; | |
Lymph node involvement; | ||
Tumour vascularity; | ||
lymphovascular invasion; | ||
Mitotic rate; | ||
Regression; | ||
Microsatellites; | ||
Tumour-infiltrating lymphocytes; | ||
Lactate dehydrogenase serum level; | ||
Tumour anatomical location: | ||
Method/Details of treatment: | ||
Details on how the melanoma was picked up: | ||
Date of excision biopsies: | Primary biopsy; | |
Secondary biopsy; | ||
Punch/Shave biopsy; | ||
Details of prescribed follow-up program: | ||
Date of recurrence diagnosis: | ||
Nature of recurrence: local, regional, distant) | ||
Melanoma type: | ||
Melanoma stage: | ||
Tumour thickness: | Breslow depth; | |
Clark level; | ||
Prognostic features: | ||
Tumour anatomical location: | ||
How was the recurrence detected: | Please Tick | |
Self – detected | ||
GP | ||
Dermatologist | ||
Follow-up appointment | ||
Other | ||
If other, please state: | ||
If self- detected, which of the following apply: | Please Tick: | |
Recurrence found via; | Routine self-examination | |
Accidental find | ||
Aid of partner/Acquaintance | ||
Experience of related symptoms (e.g. nausea, fatigue, weight loss, pain, shortness of breath etc.) | ||
Route from self-detection to official diagnosis: (e.g. Patient – GP – Hospital) | ||
Dates of above referrals: (e.g. GP referral, treatment dates etc.) |