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["GUAM CANCER REGISTRY REPORT FORM",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3]
[]
[null,null,"Physician Name:"]
[null,null,"Street Address:"]
[null,null,"City, State, Zip Code:"]
[null,null,"Telephone Number:"]
[]
[]
[]
["Patient Name (Last, First, Middle Name)",null,null,null,null,null,"Date of Birth",null,null,"Sex",null,"Social Security Number"]
[]
[]
["Residential Patient Address at Diagnosis",null,null,null,null,null,null,null,null,null,null,null,"Marital Status"]
[]
[null,null,null,null,null,null,null,null,null,"Ever Served in USA Armed Forces?"]
["Occupation (Do not write \"Retired\")",null,null,null,"Industry",null,"Race/Ethnicity",null,null,null,"Yes",null,"No"]
[]
["MUST ATTACH DOCUMENTS TO BACK UP INFORMATION BELOW: E.G. DIAGNOSTIC & TREATMENT REPORTS/SUMMARIES"]
[]
["Primary Site/Laterality of this cancer (ATTACH PATHOLOGY REPORT):"]
[]
["Histology Type of this cancer:"]
[]
["Date this cancer was FIRST DIAGNOSED:"]
[null,null,null,null,null,null,"   Month   /   Day   /   Year"]
[]
["Initial visit for this cancer:",null,null,null,null,null,null,null,null,"Most recent visit for this cancer:"]
[null,null,null,"   Month   /   Day   /   Year",null,null,null,null,null,null,null,"   Month   /   Day   /   Year"]
[null,"METHOD OF DIAGNOSIS",null,null,null,null,"PATIENT STATUS"]
[null,null,"Positive histology",null,null,null,null,"Alive, free of cancer"]
[null,null,"Positive cytology",null,null,null,null,"Alive, evidence of cancer"]
[null,null,"Autopsy",null,null,null,null,"Alive, cancer status unknown"]
[null,null,"Radiography",null,null,null,null,"Deceased, free of cancer"]
[null,null,"Clinical",null,null,null,null,"Deceased, evidence of cancer"]
[null,null,"Positive lab test marker study",null,null,null,null,"Deceased, cancer status unknown"]
[null,null,"Method Unknown"]
[]
["Did this patient receive any treatment for this cancer?",null,null,null,null,null,null,"Yes",null,"No",null,null,"Unknown"]
[]
["If \"Yes\", please complete the following:"]
[]
[]
["Surgery (specify type)",null,null,null,null,null,null,null,null,null,null,"   Month   /   Day   /   Year"]
[]
["Radiation (specify type, duration)",null,null,null,null,null,null,null,null,null,null,"   Month   /   Day   /   Year"]
[]
["Chemotherapy (specify agents, duration)",null,null,null,null,null,null,null,null,null,null,"   Month   /   Day   /   Year"]
[]
["Hormone/Other Treatment (specify type, duration)",null,null,null,null,null,null,null,null,null,null,"   Month   /   Day   /   Year"]
[]
["Referred to Physician/Hospital:"]
[null,null,null,null,"Name"]
[]
["Address",null,null,null,null,null,null,null,null,null,null,"Tel / Fax Number"]
[]
[null,null,"Please Return Completed Form To: Guam Cancer Registry, Cancer Research Center Guam"]
["GCRC1",null,null,null,null,"Dean Circle House #27, UOG Station, Mangilao, Guam 96923"]
["JAN22",null,null,null,null,"Fax: (671) 734-2990",null,null,"Phone: (671) 735-2988/0129"]

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["US Armed Forces",null,null,"METHOD OF DIAGNOSIS",null,null,null,null,"PATIENT STATUS"]
["Yes",null,null,null,"Positive histology",null,null,null,null,"Alive, free of cancer"]
["No",null,null,null,"Positive cytology",null,null,null,null,"Alive, evidence of cancer"]
[null,null,null,null,"Autopsy",null,null,null,null,"Alive, cancer status unknown"]
[null,null,null,null,"Radiography",null,null,null,null,"Deceased, free of cancer"]
[null,null,null,null,"Clinical",null,null,null,null,"Deceased, evidence of cancer"]
[null,null,null,null,"Positive lab test marker study",null,null,null,null,"Deceased, cancer status unknown"]
[null,null,null,null,"Method Unknown"]