Cardio-Oncology Patient Assessment Saint Francis Healthcare System June 13th, 2014 Cardio-Oncology Assessment Step 1 of 8 12% Have you or are you currently taking any anthracyclines or kinase inhibitors listed below?*YesNoI don't see my chemotherapy drug in the list belowI don't know Daunorubicin (Daunomycin) Daunorubicin (liposomal) Doxorubicin (Adriamycin) Doxorubicin (liposomal) Epirubicin Idarubicin Valrubicin Mitoxantrone Trastuzumab Imatinib Sunitinib *What are Anthracyclines? Group of chemotherapy drugs known to be an effective cancer treatment for cancers such as leukemia, lymphoma, sarcoma and breast cancer.Their main adverse effect is cardiotoxicity. Tend to have names ending in "rubicin." Have you gone through radiation therapy?*YesNoI don't know Do you have cardiac tumors?*YesNoI don't know Is your heart function ejection fraction (EF) normal?*No it is not normal: My ejection fraction is less than .55 or 55% AND/OR my doctor said it was not normal (or reduced)Yes it is normal: My ejection fraction (EF) is greater than .55 or 55% AND/OR my doctor said it was normalI don’t knowBased on your answers, you are not a candidate for a Cardio-Oncology consultation.Based on your answers, there is not enough information to determine if you should be consulted at at the Saint Francis Medical Center's Cardio-Oncology Clinic. If you have any questions regarding the center and what we do, please call 573-331-3333. Do you have any of the conditions listed below?*YesNoI don't know Hypertension Diabetes Smoking Family history of heart disease Hyperlipidemia Do you experience any of the symptoms below?*YesNoI don't know Short of breath Wake up short-winded in the middle of the night Irregular heart beat Chest pain Swelling of legs Extreme fatigue Sleep with more than one pillow Have you had any of the following heart-related conditions AND/OR surgery?*YesNoI don't know Heart attack Cardiac Stent Coronary Bypass Surgery Cardiac Catheterization Stroke Based on your answers, it is recommended for you to be seen at Saint Francis Medical Center for Cardio-Oncology. The Cardio-Oncology Clinic is focused on preventing and minimizing the risk of heart damage caused from chemotherapy and radiation. To make an appointment at the Saint Francis Medical Center Cardio-Oncology Clinic, please call 573-331-3333Would you like to receive a call from a clinic provider?* Yes No Based on your answers, you may consider coming in for a Cardio-Oncology consultation. The Saint Francis Medical Center's Cardio-Oncology Clinic is focused on preventing and minimizing the risk of heart damage caused from chemotherapy and radiation. Risk of heart damage from cardiotoxicity increases if your heart health changes. Our imaging specialists use strain imaging to evaluate how well your left ventricular is functioning and will have a discussion with you on how you and your doctor can help minimize the risk. Phone*PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.