E1305 Sensory Neuropathy Form NCT00588770 Chemotherapy With or Without Bevacizumab in Treating Patients With Recurrent or Metastatic Head and Neck Cancer Source Form: NCI FormBuilder:


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July 8, 2015

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E1305 Sensory Neuropathy Form NCT00588770

INSTRUCTIONS: Complete this form as indicated below and at the end of all protocol therapy. Submit original to the ECOG Coordinating Center. Keep a copy for your files.

Patient demographics
Data amendment
Off Treatment
Off Treatment Report Period (Choose one)
Adverse Events
Were adverse events assessed during this report period (Sensory Neuropathy cycle)
Blood/bone Marrow - Labs
CTC Adverse Event Term
CTC Adverse Event Grade (v4.0 this cycle)
CTC AE Attribution Code
Outcome of Adverse Event

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