Exposure in Utero Form Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder:


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September 20, 2021

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Breast Cancer NCT00659373 Toxicity - Exposure in Utero Form - 2073340v3.0

EXPOSURE IN UTERO FORM (Form 24-EIU) Instructions: Submit this form if patient becomes pregnant during protocol therapy (tamoxifen, exemestane, ovarian function suppression). If outcome is unknown, submit this form again, completing Q6-15. Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable or not done.

Mother Information
Estimated pregnancy age at beginning of exposure to Tamoxifen/Exemestane (weeks)
Outcome of pregnancy (select only one)
Perinatal problems
Newborn Information
Gender (sex)
Weight at birth (OR, if weight in grams is unknown)
Length at birth (select one unit of measure)
Ccrr Module For Exposure In Utero Form
Type of report

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