Step 1: Enter Patient Data First Name Middle Initial Last Name Medical REC Number Sex Male Female Birthdate Month January February March April May June July August September October November December Day 12345678910111213141516171819202122232425262728293031 19101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953 Year 19541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 ECOG PS Select One 0-Normal Activity1-Symptoms, but nearly fully ambulatory2-Some bed time, but needs to be in bed <50% of normal daytime3-Needs to be in bed >50% of normal daytime4-Unable to get out of bed Disease Status Select One No Evidence of Disease Localized Disease Metastatic Disease Not Clear Height Actual Weight Ideal Weight lbs Body Surface Area M2 Drug Allergies Type of Reaction