MypetQR

Patient Details

First Name

Last Name

Date of Birth

Email Id

Mobile Number

Emergency Contacts

Emergency Contact Name

Emergency Contact No.

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Medical Information

Current Diagnosis

Stage

Current Treatment

Allergies

Drug Name

https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/761163s000lbl.pdf

Immunotherapy Agent Received

Immnunotherapy Start Date

Other Diagnosis

Yes

Name of the Diagnosis

Medicine taking for other Diagnosis

Name of the Diagnosis

Medicine taking for other Diagnosis

Side Effect Management

Side effects

Side effect grading

Quality of Life tracking

Pain scores

2 Mild

Fatigue levels

10 Severe

Pruritus scores

1 None

bowel movement

8 Moderate

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Past Chemotherapy & Immunotherapy

Treatment

Treatment Regimens

Treatment Start Date

Treatment End Date

Treatment

Treatment Regimens

Treatment Start Date

Treatment End Date

Procedures

Have you had a Bone Marrow Biopsy

Have you had a Stem Cell Transplant

Have you had an Organ Transplant

Do you currently have a Pace maker or defibrillator?

Have you had Orthopedic Surgery or had a joint replaced?

Have you had Radiation Therapy?

When was your last Gynecologic exam?

When was your last mammography?

When was your last colonoscopy?

Do you have a central line or mediport?

Clinical Information

Comorbid conditions

Name of the condition

Have you been a pateint on a clinical trial?

Name of the clinical trail

Location

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Medication Management

Home medications

PRN (as-needed) medications

Over-the-counter medications

Supplements

By providing your pharmacy details and signing a consent form, you allow us to retrieve your prescription information.

Pharmacy information

Pharmacy Name

Pharmacy Contact Info

Pharmacy Email Id

Pharmacy Address

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Care Team Coordination

Oncology Provider Name

Oncology Provider Contact No.

Oncology Nurse Navigator Name

Oncology Nurse Navigator Contact No.

Nurse Navigator Name(Insurance Company)

Nurse Navigator Contact No.

Educational resources: https://www.keytruda.com/

Financial assistance: https://www.keytruda.com/financial-support/

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