Description:

CALGB-10501 CLL Medication Sheet Form NCT00513747 Early or Delayed Fludarabine and Rituximab in Treating Patients With Previously Untreated Chronic Lymphocytic Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3410013A-D230-2376-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3410013A-D230-2376-E044-0003BA3F9857

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Uploaded on:

June 12, 2015

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License :

Creative Commons BY-NC 3.0 Legacy

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CALGB-10501 CLL Medication Sheet Form NCT00513747

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

StudyEvent: CALGB-10501 CLL Medication Sheet Form
1. INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice

Header

CALGB Form

CALGB Study No

CALGB Patient ID

Date of Assessment

Are data amended

Yes

No

Patient demographics

Patient Initials (Last, First Middle)

Patient Hospital No.

Institution/Affiliate

Participating Group

Participating Group Study No

Participating Group Patient ID

Visit number

Patient Medication History

Have you taken any medications for fatigue, sleep problems, anxiety, or depression in the past two weeks

Yes

No

Agent Name (If yes)

Was agent administered

Yes

No

Comments

Footer Module

Completed by (print or type name)

Date Form Completed (MM DD YYYY)

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