Hepatobiliary Tumor Evaluation Survey
Please complete this survey to assist in the evaluation of hepatobiliary tumors. Your responses will help guide clinical assessment and care.
Patient Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Other
Contact Email Address
example@example.com
Relevant Medical History (e.g., hepatitis, cirrhosis, prior tumors)
Presenting Symptoms
*
Rows
Present
Duration (months)
Abdominal pain
1
Jaundice (yellowing of skin/eyes)
2
Weight loss
3
Loss of appetite
4
Fatigue
5
Risk Factors (select all that apply)
Chronic hepatitis B
Chronic hepatitis C
Cirrhosis
Family history of liver cancer
Heavy alcohol use
Obesity
Diabetes
None of the above
Other
Imaging Findings (if available)
Laboratory Findings (if available)
How would you rate the impact of your symptoms on daily life?
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Overall, how would you rate your current health?
*
1
2
3
4
5
Please indicate your level of agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel well informed about my condition
6
7
8
9
10
I am able to manage my symptoms
11
12
13
14
15
I have access to necessary medical care
16
17
18
19
20
Please provide any additional information you feel is relevant to your evaluation.
Submit Survey
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