Description:

PACCT-1 TAILORx Medication Form NCT00310180 Hormone Therapy With or Without Combination Chemotherapy in Treating Women Who Have Undergone Surgery for Node-Negative Breast Cancer (The TAILORx Trial) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8401EEDE-6C53-E54A-E040-BB89AD433901

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8401EEDE-6C53-E54A-E040-BB89AD433901

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Versions (3) ▾
  1. 8/26/12
  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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PACCT-1 TAILORx Medication Form NCT00310180

INSTRUCTIONS: Complete this form at the end of each cycle, and at required follow-ups if specified by the Long-Term Follow-Up Form (to report late adverse events). Submit original to the ECOG Coordinating Center. Keep a copy for your files. NOTE: The form for the last cycle should include the 30 days following the last dose of protocol drug, or until the initiation of subsequent t reatment, whichever comes first. NOTE: This form should be completed regardless of whether there are adverse events to report for the required submission report period

Header
Data amendment
On Treatment
Report Period (Choose one)
Assessment Date
Section I - Patient Characteristics
cm
Kg
Section Ii - Comorbidities (complete Section At Baseline Only)
Hypertension
Is patient on anti-hypertensive therapy
Hyperlipidemia
Hyperlipidemia
Diabetes
Diabetes (if yes, is patient taking medication for this condition)
Osteoarthritis
Osteoarthritis
Arthritic conditions other than osteoarthritis (conditions other than osteoarthritis e.g., rheumatoid arthritis)
Arthritic conditions other than osteoarthritis
Fibromylagia
Fibromyalgia
Depression
Depression
Cardiovascular Disease
Cardiovascular Disease (If yes, is patient taking medication for this condition)
Cerebrovascular disease (e.g., prior TIA)
Cerebrovascular disease
Pulmonary Disease (e.g., asthma or other chronic pulmonary conditions)
Pulmonary disease
Liver disease (e.g., hepatitis C or other conditions)
Liver disease
Neuropathy (e.g., diabetic neuropathy)
Neuropathy
Osteopenia/osteoporosis
Osteopenia/osteoporosis
Section Iii - Hormonal Medications
Current hormone therapy
Section Iv - Concurrent Medications
Number of prescription medications being taken within the last 7 days
Did the patient take any of the following within the last 7 days of visit
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