Description:

Comparison of Four Combination Chemotherapy Regimens Using Cisplatin in Treating Patients With Stage IVB, Recurrent, or Persistent Cancer of the Cervix GOG Treatment Completion Form 2059221v3.0 https://clinicaltrials.gov/ct2/show/NCT00064077

Link:

https://clinicaltrials.gov/ct2/show/NCT00064077

Keywords:

Uterine Cervical Neoplasms

Clinical Trial

Treatment Form

8/27/12 8/27/12 -
6/24/17 6/24/17 - Martin Dugas

Uploaded on:

June 24, 2017

DOI:

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License :

Creative Commons BY 4.0

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Cervical Cancer Cisplatin NCT00064077 GOG

Details

FORM Q0

1 forms

StudyEvent: GOG Treatment Completion Form
1. FORM Q0

Header Module

Date form originally completed

m d y

Date form amended

m d y

Patient Name, Last

Patient Name, First

Patient Study ID

Participating Group Code

Participating Group Protocol Number

Participating Patient Study ID

Person amending form, last name

Person Completing Form, Last Name

COMMENTS

Treatment Schedule

Total number of cycles given

Last date (any modality of) protocol therapy was given

m d y

Off-treatment Reason

Reason treatment ended (check only one)

Routine completion of planned protocol treatment (1)

Disease progression, relapse during active treatment (2)

Toxicity/side effects/complications (3)

Patient withdrawal or refusal for reason other than toxicity (4)

3 more items in the detailed view.

Specify toxicity (unnamed)

Specify reason (unnamed)

Specify disease

Will patient receive further treatment?

Yes

Specify further treatment

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Cervical Cancer Cisplatin NCT00064077 GOG

FORM Q0

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