Description:

RTOG 0825 Phase III GBM Initial Evaluation Form (I1) Temozolomide and Radiation Therapy With or Without Bevacizumab in Treating Patients With Newly Diagnosed Glioblastoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5AE2A23C-8AD1-6A8B-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5AE2A23C-8AD1-6A8B-E044-0003BA3F9857

Keywords:
Versions (3) ▾
  1. 8/26/12
  2. 1/9/15
  3. 8/4/15
Uploaded on:

August 4, 2015

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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RTOG 0825 Phase III GBM Initial Evaluation Form (I1)

INSTRUCTIONS: Submit this form at protocol entry. Dates are recorded as mm-dd-yyyy unless otherwise specified

Module 1
Amended Data (INSTRUCTIONS: Complete form on web to unblind the protocol treatment arm)
Assessment
years
Karnofsky Performance Status
Neurologic function
Disease Information
Extent of Resection
Central pathology confirmed GBM/gliosarcoma
Sufficient tissue for MGMT/molecular profile analysis
Pre-study Scans
Assessment Type
cm
cm
Pre-study Scans
Assessment Type
cm
cm
Location Of Primary
Site of Lesion
Primary Tumor Laterality
Baseline Lab Values (hematologic)
/ul
DD.MM.YYYY
1000/uL
DD.MM.YYYY
g/dL
DD.MM.YYYY
/ul
DD.MM.YYYY
DD.MM.YYYY
mg/dL
DD.MM.YYYY
mg/dL
mg/dL
g/24 hours
mg/dL
mg/dL
U/L
U/L
DD.MM.YYYY
U/L
U/L
DD.MM.YYYY
seconds
Non-protocol Therapy To Brain
Has the patient taken anticoagulant agents?
Agents with proarrhythmic potential
Herbal Products
Corticosteroids
Anticonvulsants
EIAEDS
NEIAEDS
Severe Active Comorbidity
Unstable angina
Transmural myocardial infaraction
Infection (Acute bacterial or fungal infection)
Cerebrovascular accident (including stroke)
Peripheral Vascular Disease (PVD)
Coagulation defects
AIDS
Significant vascular disease (e.g. Aortic Aneurysm, aortic dissection)
Serious nonhealing wound
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