Description:

Radiation Therapy Oncology Group Follow-up Form Phase III Recurrent Head and Neck Study Combination Chemotherapy With or Without Radiation Therapy in Treating Patients With Recurrent Head and Neck Cancer That Cannot Be Removed By Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EC4F6FCB-F88D-02BE-E034-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EC4F6FCB-F88D-02BE-E034-0003BA3F9857

Keywords:
Versions (4) ▾
  1. 9/19/12
  2. 1/9/15
  3. 8/4/15
  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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Initial Evaluation recurrent Head and Neck Cancer RTOG NCT00113399

No Instruction available.

  1. StudyEvent: Radiation Therapy Oncology Group Follow-up Form Phase III Recurrent Head and Neck Study Initial Evaluation Form
    1. No Instruction available.
Header
Amended data
years
PERFORMANCE STATUS (ZUBROD)
1000/ul
1000/uL
g/dL
mg/dL
mg/dL
U/L
U/L
U/L
U/L
U/L
U/L
mL/min
mmol/l
mg/dL
CT OR MRI OF TUMOR SITE
CHEST CT
ABDOMINAL CT
BIOPSY OF TUMOR OR NEEDLE ASPIRATE/BIOPSY OF METASTATIC LYMPH NODE
PHYSICAL ASSESSMENT OF CAROTID
DOPPLER ULTRASOUND
CT OR MR ANGIOGRAM
CIRCUMFERENTIAL TUMOR INVOLVEMENT OF CAROTID SHEATH
WAS CAROTID ARTERY STENT PLACED?
IV ANTIBIOTICS AT TIME OF REGISTRATION
HOSPITALIZED FOR COPD OR OTHER RESPIRATORY ILLNESS IN LAST 6 MONTHS
PREEXISTING GRADE > 2 PERIPHERAL SENSORY NEUROPATHY
SYMPTOMATIC OR UNCONTROLLED CARDIAC DISEASE
NEW YORK HEART ASSOCIATION CLASSIFICATION (If yes,)
PRIOR SURGERY (FOR HEAD AND NECK CANCER)
TYPE OF PATIENT DISEASE (CURRENT PRESENTATION)
T STAGE (of new primary only)
N STAGE (of new primary only)
PRIMARY SITE (CURRENT PRESENTATION)
HISTOLOGIC DIAGNOSIS (CURRENT PRESENTATION)
cm
DISTANT METASTASES PRESENT?
DOES THE PATIENT HAVE A HISTORY OF PRIOR CANCER OTHER THAN THE UPPER AERO-DIGESTIVE TRACT?
WEIGHT LOSS IN PREVIOUS SIX MONTHS
DOES THE PATIENT HAVE A PAST HISTORY OF SWALLOWING PROBLEMS?
HOW LONG WERE SWALLOWING PROBLEMS APPARENT? (If yes,)
DOES THE PATIENT CURRENTLY HAVE SWALLOWING PROBLEMS?
HOW LONG HAVE SWALLOWING PROBLEMS BEEN PRESENT? (If yes,)
DOES THE PATIENT HAVE A PAST HISTORY OF TUBE FEEDINGS?
HOW LONG WERE TUBE FEEDINGS GIVEN? (If yes,)
DOES THE PATIENT CURRENTLY REQUIRE TUBE FEEDING?
IS PATIENT DEPENDENT ON TUBE FEEDING FOR >50% OF NUTRITIONAL SUPPORT? (If yes,)
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