Description:

CALGB 90601: Medical History Form Gemcitabine Hydrochloride and Cisplatin With or Without Bevacizumab in Treating Patients With Advanced Urinary Tract Cancer NCT00942331 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=657DC836-E20A-2DC7-E040-BB89AD437499

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=657DC836-E20A-2DC7-E040-BB89AD437499

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Versions (3) ▾
  1. 8/26/12
  2. 1/9/15
  3. 5/18/15
Uploaded on:

May 18, 2015

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Creative Commons BY-NC 3.0 Legacy
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Urinary Tract Cancer Medical History Form CALGB 90601 NCT00942331

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted.

Header
Are data amended
Significant Medical History, Concomitant Diseases
Myocardial infarction (1 If multiple events, record date of most recent here, and the earlier ones in C-260 Remarks Addenda form.)
Coronary artery by-pass graft (CABG)
Cardiac stent/angioplasty
Angina pectoris
Coronary Artery Disease (heart disease)
Congestive heart failure
Hypertension
Peripheral Vascular Disease
Arterial thrombosis
Venous thrombosis
Transient ischemic disease
Cerebrovascular accident (including stroke)
Subarachnoid hemorrhage
Dementia
Chronic pulmonary disease
Connective tissue disease
Arthritis
Peptic ulcer disease
Mild liver disease
Diabetes (without complications)
Diabetes with end organ disease
Hemiplegia
Renal Disease
Diverticulitis
Prior Therapy
Prior chemotherapy?
Current bisphosphonate therapy?
Prior surgery for prostate cancer? (Mark all that apply with an X.)
Prior radiation therapy? (Mark all that apply with an X.)
Neoadjuvant hormonal therapy prior to surgery? (prostatectomy)
Neoadjuvant hormonal therapy prior to radiation? (for prostate cancer)
Adjuvant hormonal therapy after surgery? (prostatectomy)
Adjuvant hormonal therapy after radiation? (for prostate cancer)
Current type of gonadal suppression (Mark all that apply with an X.)
LHRH agonist treatment type (Mark one with an X.)
Hormonal Agent (For each hormonal agent listed below, record whether the agent was administered 0=not taken; 1=initial; 2=second line; 3=third line; 99=other reason. If administered, record agent start and end dates.)
Agent administered status (For each hormonal agent listed below, record whether the agent was administered 0=not taken; 1=initial; 2=second line; 3=third line; 99=other reason.)
Any other prior therapy?
Background Information
What is the highest grade you finished in school? (Mark one with an X.)
What is your marital status? (Mark one with an X.)
What is your current employment status? (Mark one with an X.)