Patient demographics
Patient Initials
text
Medical Record Number
text
Institution Name
text
Participating Group
text
Study Number Participating Group
text
Trial subject ID Participating Group
text
Patient Data
Documented clinical assessment for this cancer
text
Follow-Up Date
date
Patient Weight
float
Body Surface Area
float
ECOG Performance Status
text
Notice Of Progression
DiseaseProgressionInd-3
text
AdditionalTherapyAdministeredInd-3
boolean
AlternativeProtocolBeginTreatmentInd-2
boolean
Reason treatment never started, specify
text
Criteria For Treatment
ChronicLymphocyticLeukemiaTherapyClinicalTrialEligibilityCriteriaType
text
AdverseEventAssessmentDate
date
Overall Response
Person Completing Form
text
Date Form Completed
date