[% # set some accessors: patient = case.patient_case.patient; report = case.request_report; %]

HMRN Data Collection: [% report.diagnosis.name %] [[% report.diagnosis.icdo3 %]]

Please enter data into boxes, and amend any incorrect or missing details:

[% IF patient.dob %] [% ELSE %] [% END %] [% IF patient.nhs_number %] [% ELSE %] [% END %]
Patient Name: [% patient.last_name | upper %], [% patient.first_name | ucfirst %] HILIS ID: [% case.patient_case.patient_id %]
Date of Birth: [% patient.dob.strftime('%d.%b.%Y') %]Date of Birth:  NHS No: [% PROCESS site/nhs_number.tt nhs_number = patient.nhs_number %] NHSNo:   [PatNo: [% case.patient_case.unit_number %]]
HMDS Number: [% INCLUDE site/lab_number.tt data = case %] Report Date: [% authorisation_date.strftime('%d.%b.%Y') %]
Source: [% case.patient_case.referral_source.display_name %] [[% case.referrer_department.referrer.name %]] Specimen: [% specimen_map.item(case.id).sample_code.join(', ') %]
Demographics:
Gender:   M  /  F   Date of diagnosis:  
Address at diagnosis:  
GP address:  
1st appointment on:   Palliative date:  
Date of death:    
Antecedent / concurrent events:
Event:  
Therapies:   chemotherapy  /  radiotherapy   /  both  
Treatment history:
Centre: [name]
Treatment: [treatment name]
Trial: [trial name]
Start date:   End date:   Response: