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7-A CACI – Co morbidity unoact on survival rate – Elderly Specialist
Document ID
*
1. Age
*
Select
41 - 50
51 - 60
61 - 70
71 - 80
>80
2. Myocardial infarction
*
Select
Yes
No
3. Congestive heart failure
*
Select
Yes
No
4. Peripheral vascular disease
*
Select
Yes
No
5. Cerebrovascular disease
*
Select
Yes
No
6. Dementia
*
Select
Yes
No
7. Chronic pulmonary disease
*
Select
Yes
No
8. Rheumatic disease
*
Select
Yes
No
9. Mild liver disease
*
Select
Yes
No
10. Diabetes mellitus without end-organ damage
*
Select
Yes
No
11. Diabetes mellitus with end-organ damage
*
Select
Yes
No
12. Hemiplegia
*
Select
Yes
No
13. Renal disease
*
Select
Yes
No
14. Any malignancy
*
Select
Yes
No
15. Lymphoma
*
Select
Yes
No
16. Leukemia
*
Select
Yes
No
17. Moderate liver disease
*
Select
Yes
No
18. Metastatic solid tumor
*
Select
Yes
No
19. Acquired immunodeficiency syndrome (AIDS)
*
Select
Yes
No
Consent
*
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