Description:

CGV Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FF18B4D3-D937-1066-E034-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FF18B4D3-D937-1066-E034-0003BA3F9857

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

June 9, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Header module
Answer Questions 3-8 Relating To Acute Gvhd
Maximum overall grade of acute GVHD during this assessment period
Did clinical signs and/or symptoms of acute GVHD develop during this assessment
Record method used to diagnose acute GVHD
Was prophylaxis for GVHD given during this assessment period
If Yes, Specify All Immuno Suppressants Used For Gvhd Prophylaxis
Cyclosporine
Tacrolimus
Sirolumis
MMF
Prednisone
Other
Answer Questions 9-19 Relating To Chronic Gvhd
Maximum overall severity of chronic GVHD during this assessment period
Maximum overall grade of chronic GVHD during this assessment period
Current Karnofsky/Lansky score
Record method used to diagnose chronic GVHD
1000/uL
Kg
mg/dL
Indicate The Maximum Severity Of Involvement For The Following Organ Systems During This Assessment Period
Myositis
Extent of skin involvement
Lichenoid
Maculpapular
Sclerodermatous
Xerophthalmia
Bronchiolitis obliterans
Esophagus
Diarrhea (number of stools)
Diarrhea (volume of stools)
Contractures
Eosinophilia
Serositis
Fascitis
Answer Questions 42-48 Related To Biopsies Performed During This Assessment Period
Were any biopsies performed during this assessment period for suspected GVHD
Result of biopsy
Type of biopsy
Answer Questions 49-52 Relating To Gvhd
Was a specific therapy used to treat GVHD during this assessment period
If Yes, Indicate Whether Or Not The Agents Listed Below Were Used To Treat Gvhd During This Assessment Period
Other
Has treatment been discontinued
ALS, ALG, ATS, ATG
Azathioprine
Cyclosporine
Systemic corticosteriods
Topical corticosteroids
Thalidomide
Tacrolimus
Mycophenolate Mofetil
PUVA (Psoralen and UVA)
ECP (Extra-corporeal photopheresis)
Sirolumis
Etretinate
Lamprene
Etanercept
Zenapax
Chloroquine phosphate
In vivo anti T-lymphocyte monoclonal antibody
Specify in vivo anti T-lymphocyte monoclonal antibody used
Answer Questions 53-56 Relating To Current Patient Status
Are symptoms of GVHD still present
Current Karnofsky/Lansky score
1000/uL
Kg

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