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Name

DOB (Age)

Gender

Phone number

Email Id

Country/Location

Primary Diagnosis

Date of Diagnosis

Current Symptoms

Previous Medical Conditions

Allergies

Current Treatment Plan

Previous Treatments Received

Medications

Surgeries (if any)

Radiation therapy (details)

Response to Treatments

Current Medications and Supplements

Attach Reports (if available)

Pathology Reports

Imaging Reports (CT, MRI, PET scans, etc.)

Blood Tests (e.g., tumor markers, CBC, liver/kidney function tests)

Genetic Testing (if any, e.g., EGFR, HER2, BRCA mutations)

Recent Imaging Date and Findings

What specific areas do you need a second opinion on?

Are you seeking recommendations for alternative treatments?

Eli Lilly and Company