Data Collection Form - Sgo

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ENDOMETRIAL CANCER
OPERATIVE CARE AND
POSTOP COMPLICATIONS
WITHIN 30 DAYS
Data Collection Form
Updated: August 25, 2014
I. PATIENT DEMOGRAPHICS
Medical Record Number
Date of Birth
Zip Code
White/Caucasian
Asian
Native Hawaiian/Pacific Islander
Unknown
Race (select all applicable)
African American
American Indian/Alaskan Native
Hispanic/Latino/Spanish
Chose Not to Disclose
If Yes to patient history of cancer, indicate type of cancer and age patient was diagnosed:
Patient History of Cancer:
Ovarian
Other
Age Patient Diagnosed:
Breast
Colon
Yes
No
If Yes to family history of cancer, indicate type of cancer, relative category and age relative was diagnosed:
Relative (optional)
Family History of Cancer:
1st Degree
(optional)
Yes
No
Breast
Colon
Ovarian
2nd Degree
Age Relative Diagnosed:
3rd Degree
II. HOSPITALIZATION
Hospital Admit Date
Hospital Discharge Date
III. PREOPERATIVE RISK FACTORS
Height (cm)/(in)
Weight (kg)/(lb)
Body Mass Index (Calculated field)
ASA Class (time of surgery)
1
2
3
4
Diabetes:
Yes
No
If Yes, Select Medication:
None
Insulin
Oral Hypoglycemic
Current Smoker (within one year of surgery):
Yes
No
History of Conditions/Previous Interventions (select all applicable):
Prior Abdominal Surgery:
Yes
No
Year:____________________________
Cardiac Surgery (includes: stent, CABG, Valve, Pacemaker, Other Cardiac Surgery):
Yes
No
Creatinine level >1.5:
Yes
No
Steroid Use (Use of oral/parenteral steroids for >10 days in prior 30 days):
Yes
No
Pulmonary:
Yes
No
COPD
Pulmonary HTN
Other
Heme:
Yes
No
DVT/PE (within 90 days)
Transfusion
Other
Neuro:
Yes
No
Stroke
Other
Endocrine:
Yes
No
Thyroid Hyper
Thyroid Hypo
Afib/Arrhythmia
Angina (within 30 days)
CHF (within 30 days)
Cardiac Conditions
Yes
No:
HTN
MI (within 6 months)
Other
Presurgical Radiotherapy:
Yes
No
IV. HISTOLOGY
Serous
Clear Cell
Carcinosarcoma
Endometrioid
Mixed
Other:
Largest Primary Tumor Diameter (cm)
Lymphovascular Space Invasion:
Yes
No
Unknown
Myometrial Invasion:
None
≤ 50%
> 50%
Cervical Stromal Invasion:
Yes
No
1192SGO-0825

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