Description:

E1305 Chemotherapy Treatment Form NCT00588770 Chemotherapy With or Without Bevacizumab in Treating Patients With Recurrent or Metastatic Head and Neck Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3ED4DA74-CDF5-35B6-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3ED4DA74-CDF5-35B6-E044-0003BA3F9857

Keywords:
Versions (3) ▾
  1. 9/19/12
  2. 1/8/15
  3. 6/8/15
Uploaded on:

June 8, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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E1305 Chemotherapy Treatment Form NCT00588770

INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule).

Header
Patient demographics
Data amendment
Arm A And Arm B
On Treatment Report Period
On Treatment
Patient Vital Status
Primary Cause of Death (if applicable)
Patient status assessment
ECOG Performance Status (Day 1 of this cycle)
Kg
m2
Therapy Administered - Cisplatin
Dose modification
Dose Modification Reason
Therapy Administered - Carboplatin
Dose modification
Dose Modification Reason
Therapy Administered - Docetaxel
Dose modification
Dose Modification Reason
Therapy Administered - 5FU
Dose modification
Dose Modification Reason
Chemotherapy Dose Modifications
mg/dL
Carboplatin was administered
Is this first administration of carboplatin in place of cisplatin for this patient (Carboplatin Substitution Section only to be completed if patient was on Cisplatin regimen and Carboplatin was administered as a substitution for Cisplatin)
Toxicities that led to the substitution (If yes, - mark all that apply - )
Adverse Event (Instructions: If any agent dose was modified for adverse event, mark an 'X' for all that apply:)
Non-protocol Therapy
Was any non-protocol therapy given during protocol treatment?
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