Description:

E5103 Cardiac Toxicity Form [Form No. 2608v2] NCT00433511 Doxorubicin, Cyclophosphamide, and Paclitaxel With or Without Bevacizumab in Treating Patients With Lymph Node-Positive or High-Risk, Lymph Node-Negative Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=22AFF315-4EDF-593F-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=22AFF315-4EDF-593F-E044-0003BA3F9857

Keywords:
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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E5103 Cardiac Toxicity Form NCT00433511

INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center within one week of registration. Keep a copy for your files

ECOG clinical trial administrative data
Patient demographics
Data amendment
On Treatment
On Treatment Report Period (Choose one x)
Off Treatment
Off Treatment Report Period (since registration)
Cardiovascular assessment
Has the patient had a documented assessment of cardiac function (this report period)
Method of Evaluation (LVEF)
%
%
Clinical Episode of CHF (requires symptoms associated with a decrease in LVEF to below the institutional LLN - Specify whether any of the following adverse events have occurred during this report period record an answer for each event listed below)
S3 Gallop
Basilar Rales
Dyspnea on exertion, orthopnea or paroxysmal noctural dyspnea
Was dyspnea grade 1 (If yes to Dyspnea:)
Cardiomegaly
Abnormal ECG (<specify>)
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