Description:

IBCSG Long Term Follow-Up Medication Form (18-LTF-M) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=889C3F60-2C7B-8540-E040-BB89AD4303DD

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=889C3F60-2C7B-8540-E040-BB89AD4303DD

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Versions (2) ▾
  1. 8/26/12
  2. 6/20/17
Uploaded on:

June 20, 2017

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License:
Creative Commons BY-NC 3.0
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IBCSG Long Term Follow-Up Medication Form (18-LTF-M)

Instructions: This form is to be completed if the patient received bone active medication, non-steroidal, anti-inflammatory drug or extended adjuvant therapy during this follow-up period. Use minus one (-1) to indicate that an answer is unknown, unobtainable or not done

Header Module
Long Term Follow-up Medication
Did the patient receive bone active medication other than calcium or vitamin D during this follow-up period (e.g., bisphosphonates)
If yes or continuing
Did the patient receive glucocorticosteroids during this follow-up period
Did the patient receive continuous, non-steroidal, anti-inflammatory drug during this follow-up period (e.g., COX-2 inhibitors, aspirin, Ibuprofen)
Did patient receive extended adjuvant endocrine therapy for primary breast cancer during this follow-up period (If treatment was given for breast cancer recurrence, do not record)
Adjuvant Hormonal Therapy Administered Type (Extended)
Reason Stopped (If extended treatment stopped, what was the reason)
Footer Module
day month year