E1305 Bevacizumab Treatment Form - Arm B Only NCT00588770 Chemotherapy With or Without Bevacizumab in Treating Patients With Recurrent or Metastatic Head and Neck Cancer Source Form: NCI FormBuilder:

  1. 9/19/12 9/19/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
  3. 6/8/15 6/8/15 -
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June 8, 2015

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Creative Commons BY-NC 3.0 Legacy
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E1305 Bevacizumab Treatment Form - Arm B Only NCT00588770

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

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)
Therapy Administered - Bevacizumab
Was the agent Bevacizumab administered during this reporting period
Dose modification
Dose Modification Reason (If applicable)
Adverse Event (If Bevacizumab dose was modified for adverse event, mark all that apply)
Non-protocol Therapy
Was any non-protocol therapy given during protocol treatment?
Anti-coagulant Therapy
Were any low-dose anticoagulant drugs administered during this reporting period
Anti-Coagulant Drugs
Anti-hypertensive Therapy
Were any antihypertensive drugs administered during this reporting period
Anti-Hypertensive Drugs

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