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Contact details
Trial-IN Pharma Ltd
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[email protected]
Phone
: +972-58-4445108
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Date (שדה חובה)
Name and Surname (שדה חובה)
ID No. (שדה חובה)
Type of cancer (שדה חובה)
Name and Surname (שדה חובה)
Relation to patient (שדה חובה)
E-mail (שדה חובה)
Mark:: Grade 0 - Fully active, able to carry on all pre-disease performance without restriction (שדה חובה)
Mark:: Grade 2 - Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours (שדה חובה)
Mark:: Grade 3 - Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours (שדה חובה)
Mark:: Grade 1 - Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work (שדה חובה)
Mark:: Grade 4 - Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair (שדה חובה)
I have read and understood the topic of the performance status questionnaire (שדה חובה)
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