Demographics
Date of report
date
Age
integer
Weight
float
Height
integer
Body Surface Area
float
Diagnosis
text
Description
Type of treatment
integer
Administration Start Date
date
Administration End Date
date
Drug
text
Total Daily Dose
text
Route
text
Protocol Treatment
Date of protocol initiation
date
previous toxicity on this protocol
text
Course # for this toxicity
integer
Date course started
date
Drugs and Doses for this Course
Cumulative Totals to Date
Serious Adverse Event
Hospitalization
text
drug dose reduced
text
SAE reaction
text
drug re-introduction
text
SAE reaction reappear
text
Pretreatment Counts for this Course
Nadir Counts
GOG #
Disease sites
text
Concurrent non-malignant disease
text
Concurrent non-protocol medication
text
history of organ dysfunctions
text
Comment
text
Quality of Life Cover Sheet (Investigator's details)
Time of Today's Assessment
Cisplatin or Cisplatin/Topotecan
integer
MVAC
text
Protocol Regimen Schedule
integer
QoL assessment completion
boolean
Assistance to patient
text
reason for uncompleted questionnaire
integer
Other reason
text