Section 1: Patient Information

File Number:
Identity Number:
Date of Birth:

Section 2: Socio-Demographic Data

Province: Eastern CapeFree StateGautengKwaZulu-NatalLimpopo, MpumalangaNorthern CapeNorth WestWestern Cape
Ethnicity: AsianBlackColouredIndianWhiteOther
Highest Education Level Achieved:
Employment: EmployedUnemployed
Household Type: UrbanRuralTownshipInformal Settlement

Living Conditions:

Electricity: YesNoUnknown
Running Water: YesNoUnknown
Distance to Referral Hospital: <50km50-100km100-200km200-400km>400km
Date of the first referral note/or if possible, first presentation at healthcare facility (1st presenting facility):
Referral From:
Medical Sector: Public HealthcarePrivate Healthcare
If Private Healthcare is selected: Private FundingMedical Aid
If Medical Aid is selected, please specify details:

Section 3: Medical History

HIV Status: HIV+HIV-Unknown

Complete if HIV+:

Medication: CD4>350CD4 200-350CD4<200CD4=Not on ARV'sOn ARV's
Date Medication Started:
Nutritional Status: HBALBProtein
Clinical Diseases: YesNoUnknown
If Yes is selected, please specify details:
Weight at time of diagnosis (kg):
Height (cm):
BMI:
Obstetrical History: GravidityParityAbortionMiscarriage
History of Smoking: YesNoUnknown
Substance Abuse: YesNoUnknown
BRCA 1/2 Mutation: YesNoUnknown
Hormonal Contraception: YesNoUnknown
Menarche (Year):
Menstural Cycle: RegularIrregularAmenorrheaUnknown
Breastfeeding History: YesNoUnknown
Other relevant personal history:
Other relevant family history:

Section 4: Oncological Diagnosis

REGISTERED AS A YOUNG FEMALE PATIENT WITH A CANCER DIAGNOSIS THAT IS NOT ASSOCIATED

With a pregnancy: YesNo
Date of Primary Diagnosis:
Type of Cancer:
Stage of Cancer:
FIGO stage (If appicable):

Please Complete the following for breast cancer:

Side of Affected Breast: LeftRightUnknown
Presenting Symptoms: SymptomaticAsymptomaticUnknown
Lump: YesNoUnknown
Mastitis: YesNoUnknown
Peau d'orange: YesNoUnknown
Nipple Discharge: YesNoUnknown
Nipple Inversion: YesNoUnknown
Other: YesNoUnknown
Details for Other:

ADDITIONAL PATHOLOGY AND TUMOUR MARKER AND IHC INFORMATION

Pathology:

Tumor Size (mm):
Tumor Grading:
Peritumoural lymphovascular invasion:

Tumourmarker:

Type:
Value:
Additional Information:

Section 5: Oncological Treatment

Fertility Preservation: YesNoUnknown
Surgery: YesNoUnknown
Date:
Type:
Chemotherapy: YesNoUnknown
Start Date:
Completion Date:
Regimen:
Cycles:
Radio Therapy: YesNoUnknown
Start Date:
Completion Date:
Type:
Fractions:
Additional Information:

Section 6: Follow Up

Follow Up Date:
Follow Up Date Further Information: Persistent DiseaseRemissionRecurrence
Side Effects of Treatment:

Section 7: Obstetrical Data & Delivery Day

Basic Information:

PGAM: PGAMUnknown
Weight at start of Pregnancy (kg):
Conception: NaturalReproductive Technique

FOR REPRODUCTIVE TECHNIQUE ONLY:

Ovulation InductionIUIIVFICSIUnknown
Singleton/Multiple Pregnancy:
Expexted Date of Delivery:
Delivery Date influenced y Cancer Diagnosis or Treatment: YesNoUnknown
Delivery Plan: Normal Vaginal DeliveryCaesarean Section
Interventions During Pregnancy: YesNoUnknown
Gestational and Medical Complications During Pregnancy: YesNoUnknown
If YES, please explain:
Medication Used During Pregnancy: YesNoUnknown
If YES, please mention all medication used except for chemotherapeutics:

DELIVERY INFORMATION:

Date of Delivery:
Maternal Weight at Delivery (kg):
Onset of Labour: SpontaneousInduction
Delivery: Normal Vaginal DeliveryCaesareanAssisted Delivery
Days Spent in Hospital:

Placenta:

Weight (kg):
Histology Performed: YesNoUnknown
Metastasis: YesNoUnknown
Complications or Remarks on Delivery Postpartum Period:

Section 7: Child Information

Child Code:
Gender: BoyGirlUnknown

ON THE DAY OF BIRTH:

Weight:
Height:
Head Circumference:
Apgar Score 1:
Apgar Score 3:
Apgar Score 10:

Umbilical Cord Blood:

Arterial pH:
Base Excess:
Venous pH:
Base Excess:
Abnormalities at Physical/Technical Examinations: YesNoUnknown
Congenital Malformations: YesNoUnknown
Abnormalities at the Neurological Examinations: YesNoUnknown
Admitted to NNICU: YesNoUnknown
Apgar Score 1:
Apgar Score 1:
Apgar Score 1:

FOLLOW UP - 1 WEEK:

Weight:
Height:
Head Circumference:

Vaccinations:

1. TOPV1 (POLIO): YesNoUnknown
2. BCG (T.B): YesNoUnknown

FOLLOW UP - 8 WEEKS:

Weight:
Height:
Head Circumference:

Vaccinations:

1. TOPV1 (POLIO): YesNoUnknown
2. ARV1 (ROTAVIRUS): YesNoUnknown
3. PCV1 (PNEUMOCOCCAL): YesNoUnknown
4. Dtap-IPV//Hib1 (5-in-1): YesNoUnknown
5. HEPB1 (HBV): YesNoUnknown