Gender*

Male Female

Pulse Rate*

bpm

Systolic Blood Pressure*

mmHg

Diastolic Blood Pressure*

mmHg

Hemoglobin*

g/dL

Oxygen Saturation*

%

D-dimer*

ng/mL

Hemoptysis*

Yes No

Acute Dyspnea*

Yes No

One Leg Edema*

Yes No

Stage of Cancer*

1 2 3 4

Type of Cancer*

Solid Hematologic