Description:

NCT00087178 NSABP PROTOCOL B-36 Baseline Menstrual History Questionnaire Comparison of Two Combination Chemotherapy Regimens in Treating Women With Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C893003F-B432-7480-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C893003F-B432-7480-E034-0003BA12F5E7

Keywords:
Versions (3) ▾
  1. 8/26/12
  2. 1/9/15
  3. 7/5/15
Uploaded on:

July 5, 2015

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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NCT00087178 NSABP PROTOCOL B-36 Baseline Menstrual History Questionnaire

(For all B-36 Patients)

  1. StudyEvent: NSABP PROTOCOL B-36 Baseline Menstrual History Questionnaire
    1. (For all B-36 Patients)
Header
Date Questionnaire Completed
Section A
Have you had your uterus removed?
Have you had both your ovaries removed?
Have you had a menstrual period or vaginal bleeding in the last 12 months? (If you have had bleeding in the last 12 months, continue to Section B. Otherwise, stop here.)
Section B
Did your periods stop or become less frequent during the last 12 months?
Have you taken hormone replacement therapy (estrogen and/or progesterone) at any time in the last 12 months?
Have you taken hormonal contraceptives (birth control pills, Norplant, Depo-Provera) at any time in the last 12 months?
Ccrr Module For Nsabp Protocol B-36 Baseline Menstrual History Questionnaire

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