Description:

TX5 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FF1AAC43-4B80-4030-E034-0003BA3F9857

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https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FF1AAC43-4B80-4030-E034-0003BA3F9857

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Versions (4) ▾
  1. 9/19/12
  2. 8/7/14
  3. 6/2/15
  4. 9/20/21
Uploaded on:

September 20, 2021

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License:
Creative Commons BY-NC 3.0 Legacy
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Header module
Record The Highest Grade Of Toxicity Diagnosed Since The Previous Evaluation. If This Is The First Evaluation, Record The Highest Toxicity Diagnosed Since Day 0. The Toxicity Grades Are Based On The Nci Ctcae Version 3.0.
Allergy/immunologic Toxicity
Allergic reaction/hypersensitivity (including drug fever)
Autoimmune reaction
Gi Toxicity
Mucositis/stomatitis (clinical exam)
Renal Toxicity
Hemorrhagic cystitis
Did the patient experience renal failure severe enough to warrant dialysis
Did the patient receive dialysis
Hemorrhagic Toxicity
Hemorrhage
Cardiovascular Toxicity
Hypotension
Cardiac arrhythmia
Left ventricular systolic dysfunction
Neurologic Toxicity
Somnolence
Record seizure toxicity
Did the patient experience any seizures during this assessment period
Coagulation Toxicity
HUS/TTP/thrombotic
Vascular Toxicity
Vascular leak syndrome
Pulmonary Toxicity
Hypoxia (for more and 24 hours)
Dyspnea
During this assessment period, was an FEV1 performed
During this assessment period, was an FVC performed
Hepatic Toxicity
Did The Patient Develop Any Of The Following Clinical Sugns/symptoms Of Abnormal Liver Function During This Assessment Period
Hepatomegaly
Weight gain (>5%) from baseline
Jaundice
Right upper quadrant pain
Other clinical signs/symptoms
Indicated The Etiology Of The Abnormal Liver Function
Vod
Etiology
Biopsy results
Doppler ultrasound results
Gvhd
Etiology
Biopsy results
Doppler ultrasound results
Infection
Etiology
Biopsy results
Doppler ultrasound results
Other
Etiology
Biopsy results
Doppler ultrasound results
Unknown
Etiology

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