Description:

RTOG-0522 A5: Demographic Data Form NCT00265941 Radiation Therapy and Cisplatin With or Without Cetuximab in Treating Patients With Stage III or Stage IV Head and Neck Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FA3C72BE-9A73-28F6-E034-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FA3C72BE-9A73-28F6-E034-0003BA3F9857

Keywords:
Versions (6) ▾
  1. 9/19/12
  2. 8/11/14
  3. 8/11/14
  4. 1/9/15
  5. 1/9/15
  6. 7/3/15
Uploaded on:

July 3, 2015

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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RTOG-0522 A5: Demographic Data Form NCT00265941

No Instruction available.

  1. StudyEvent: RTOG-0522 A5: Demographic Data Form
    1. No Instruction available.
Header
Amended Data
Who completed this form (Check one box)
Patient demographics
Patient Race Category
Patient Ethnic Group Category (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
Highest school grade completed
Religion during childhood (Check one box)
Marital status (Check one box)
Where were you born (Check one box)
Where did you live the longest (Check one box)
Cigarette History
Smoked at least 100 cigarette during lifetime (5 packs)
If you have had any of the illnesses listed below, please check yes for those that apply (check = Yes)
Family History
Are you adopted (Check one)
Blood relative with cancer (check = yes)
Type of Cancer (check = yes)
Have you ever heard of Cancer Prevention Trials (Check one box)
How likely would you be to volunteer to participate in Cancer Prevention Trials (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)

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