Description:

Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer NCT00024102 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50D6435-FF10-3254-E034-080020C9C0E0

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50D6435-FF10-3254-E034-080020C9C0E0

Keywords:

Quality of Life

Breast Neoplasms

8/26/12 8/26/12 -
3/18/15 3/18/15 - Martin Dugas

Uploaded on:

March 18, 2015

DOI:

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License :

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer combination chemotherapies (NCT00024102)

Scoring: Score 1 for each incorrect response; maximum weight score=28.

StudyEvent: CALGB: ORIENTATION-MEMORY-CONCENTRATION TEST FORM
1. Scoring: Score 1 for each incorrect response; maximum weight score=28.

Header

CALGB Form

CALGB Study No

CALGB Patient ID

Date Completed (M)

Amended data?

Yes

No

Patient's Name

Participating Group

Patient Hospital Number

Participating Group Protocol No.

Main Member Institution/Adjunct

Participating Group Patient No.

Completed By (Print or Type Name)

Assessment Number (1.)

Orientation-memory-concentration Test

What year is it now? (Patient's Response)

Score (Weight)

Final Score

What month is it now? (Patient's Response)

About what time is it? ([within 1 hour])

TOTAL SCORE

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