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1176
Description
Prior Treatment History Form (Form 24-H) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B1274765-836E-53AF-E034-0003BA12F5E7
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- 8/27/12 8/27/12 -
- 1/9/15 1/9/15 - Martin Dugas
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August 27, 2012
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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Pre-Study - Prior Treatment History Form (Form 24-H) - 2074666v3.0
PRIOR TREATMENT HISTORY FORM (Form 24-H) Instructions: This form collects data on treatment of breast cancer prior to randomization. Please submit within one (1) month of randomization. Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.
- StudyEvent: Prior Treatment History Form (Form 24-H)
Similar models
PRIOR TREATMENT HISTORY FORM (Form 24-H) Instructions: This form collects data on treatment of breast cancer prior to randomization. Please submit within one (1) month of randomization. Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.
- StudyEvent: Prior Treatment History Form (Form 24-H)
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Before Diagnosis: Chemoprevention For Breast Cancer
IndicatewhichchemopreventionagentsthepatientreceivedBEFOREDIAGNOSISandindicatethenumberofmonthspatientreceivedtheseagents.
Item
Indicate which chemoprevention agents the patient received BEFORE DIAGNOSIS and indicate the number of months patient received these agents. (select all that apply by marking an ?X? in the appropriate Therapy.)
text
AgentName
Item
Other, specify (therapy)
text
AgentName
Item
Other, specify (therapy)
text
MONTHS
Item
MONTHS
text
AgentEndDate
Item
DATE STOPPED (If continuing, use -1)
date
Item Group
Prior Chemotherapy Regimen For Breast Cancer
Item
Did patient receive adjuvant and/or neoadjuvant chemotherapy for breast cancer? (Mark your selection with an ?X? in the appropriate boxes.)
text
Code List
Did patient receive adjuvant and/or neoadjuvant chemotherapy for breast cancer? (Mark your selection with an ?X? in the appropriate boxes.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
CL Item
Neoadjuvant Only (Neoadjuvant only)
CL Item
Adjuvant Only (Adjuvant only)
CL Item
Both Adjuvant And Neoadjuvant (Both adjuvant and neoadjuvant)
PriorChemotherapyBeginDate
Item
Date of first dose of chemotherapy (day month year)
date
AgentName
Item
Other, specify (therapy)
text
AgentName
Item
Other, specify (therapy)
text
AgentName
Item
Other, specify (therapy)
text
AgentCountCoursesAdministered
Item
Neoadjuvant Total Number of Cycles
double
AgentCountCoursesAdministered
Item
Neoadjuvant Total Number of Cycles
double
AgentEndDate
Item
DATE STOPPED (If continuing, use -1)
date
AgentTotalDose
Item
Agent Dose
double
AgentTotalDose
Item
Agent Dose
double
AgentAdminRoute
Item
Route
text
OtherSERM,
Item
Other SERM, (specify)
text
AgentBeginDate
Item
DATE STARTED (D M Y)
date
InvestigatorSignature
Item
Investigator/Designee Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date (day month year)
date
PatientStudyID,CoordinatingGroup
Item
Patient ID Number (Study No.)
text
PatientInitialsName
Item
Patient Initials (f m fl sl)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
PatientBirthDate
Item
Patient's Date of Birth (day)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
MainMemberInstitution/Affiliate
Item
Participating Center/Affiliate
text
ParticipatingGroupCode
Item
Center Code (Ver.#1)
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)