New Jersey Department of Health

Cancer Epidemiology Services

PO Box 369, Trenton, NJ 08625-0369

Phone: (609) 633-0500 Fax: (609) 633-7509

PHYSICIAN REPORT FORM (NON-HOSPITAL SOURCE) (09700)	FOR OFFICE USE ONLY
CTR Number:	__________________
Physician Name:
Street Address:
City, State, Zip Code:
Telephone Number:
Patient Name
Date of Birth
Social Security Number
Patient Address
Race/Ethnicity
Marital Status
Sex
City, State, Zip Code
Occupation
Industry
Primary Site/Laterality of this cancer (attach pathology report):
Histology Type of this cancer:
Date this cancer was FIRST DIAGNOSED:	/ /
Month/Day/Year
Initial visit for this cancer:	/ /
Month/Day/Year
Most recent visit for this cancer:	/ /	Alive Dead
Month/Day/Year
STAGE INFORMATION (Please refer to AJCC Cancer Staging Manual.)
Primary Tumor (T)	Regional Lymph Nodes(N)	Direct Metastasis (M)	Stage Group
Tumor Size:
For malignant melanomas, record size, depth and thickness
Tumor Markers:
Name
Results
LDH Results
Clinical Lymph Node Status @ Dx:
Did this patient receive any treatment for this cancer?	Yes No	If “Yes,” please complete the following:
Active Surveillance/watchful waiting?	Yes No
/	/
Surgery (specify type)	(margin status)
Month	Day	Year
/	/
Radiation (specify agents, duration, 1st course or subsequent)
Month	Day	Year
/	/
Chemotherapy (specify agents, duration, 1st course or subsequent)
Month	Day	Year
/	/
Hormone (specify type, duration)
Month	Day	Year
/	/
Immunotherapy/Other Treatment (specify type, duration)
Month	Day	Year
Referred to Physician/Hospital:
Provider Name	Address, Suite, City, Zip	Phone Number

CES-40

AUG 13	USE BACK OF FORM FOR ADDITIONAL COMMENTS

CES-40, Physician Report Form

CES-40, Physician report, 09700, cancer epidemiology services, CES

EWhite

2012-03-20

NJDOH