Stereotactic Radiosurgery Institute

95 North Greenleaf Street | Gurnee, IL 60031 | tel: 847-249-3090 | fax: 815-301-3883
Providing Services at: The Rotating Gamma System Institute, Gurnee, IL, Advanced Radiation Oncology Center, Gurnee, IL, Vista Medical Center, Waukegan, IL, St. Francis Hospital, Evanston, IL

Presented by Tomasz K. Helenowski, M.D.

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Patient Selection

A multidisciplinary team of professionals including neurosurgeons, radiation oncologists, neuroradiologists, neuropathologists, and otolaryngologists help determine whether or not stereotactic radiosurgery is a treatment option for an individual. They consider the patient's age, general health, previous surgeries, and treatments. Available scans, angiograms, and xrays are studied to evaluate the size, shape, location, and growth pattern of the lesion. The merits of alternative treatments such as chemotherapy, conventional radiation therapy, and traditional surgery are also considered to recommend treatment alternatives for the patient.

The following items are need for review:

1. A cover letter and questionnaire stating the name, address, telephone number of the person who wishes to be reviewed as a potential Radiosurgery patient. This letter can be written by a referring physician, family member, or the patient.

2. Copies of CT, MRI, PET, or angiogram studies. Please be sure to include the most recent studies and previous studies for comparison. The actual films or pictures are needed for review. We recommend sending the films by a carrier who can trace the package.

3. Copies of pathology reports which pertain to the brain lesion.

4. Copies of the treatment plan and portal films if any radiation therapy was received.

5. A copy of the patient's medical and surgical history and questionnnaire (See below or in PDF Format.)

6. Address to :

Tomasz K. Helenowski, M.D.
95 North Greenleaf Street
Gurnee, Illinois 60031-3309

(tel) 1-847-249-3090
(fax) 1-815-301-3883

7. Please label all correspondences with "Radiosurgery Candidate".




Stereotactic Radiosurgery Institute Questionnaire

(Please print out this web page or PDF Form and fill in answers.)

Today's Date:

Patient Name:

Patient Date of Birth:

Patient Social Security Number:

Patient Contact Name:

Patient Contact Relationship to Patient:

Patient Contact Telephone Number:

Patient Contact Mailing Address:

Main Complaint (The problem that the patient is being evaluated for presently):


What problems led to the diagnosis (Please list dates of each problem)?


What problems is the patient having now (Weakness, numbness, seizures, etc.)?

Does the patient have claustrophobia?

Is the patient working? (Circle one below)
Full Time
Part Time
Not Working

If the patient is not working, did they stop because of the illness?

when did they stop working?

Is the patient walking? (Circle one below)
Independently
With a Cane
With a Walker
With Assistance
Self Transfer to Wheel Chair
Bedridden with Full Assisted Transfer to Wheel Chair

Is the patient able to communicate well? (Circle one below)
Normally
Has some problems understanding
Has some problems expressing themself
Has severe problems understanding
Has severe problems expressing themself
No communication possible

How is the patient's memory? (Circle one below)
Normal
Somewhat Impaired
Very Poor

What is the patient's level of awareness? (Circle one below)
Alert and Normal
Sleepy but can initiate conversation
Sleepy and only responds to stimulation briefly
In a coma

Is the patient able to take care of their Personal Self Care? (Circle one below)
Alone without help
With Some Assistance
With Major or Full Assistance

How is the patient's personality? (Circle one below)
Normal
Affected


Please list the patient's medications (Name, Dose, and Frequency):



Please list any allergies or adverse reactions to medications:



Please list any medical problems:


Heart:

Lung:

Digestive:

Other:

Please list dates and previous surgeries performed:



Please list dates and location (brain, lung, etc.) of any radiation therapy delivered, doctor who treated patient, and address:





Please list dates of any chemotherapy and list tumor treated with the chemotherapy:



Please list dates of scans and angiograms performed and where they were done. Also list the results of the scans if you know them.



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