Ccrr Module For Calgb 90202: Prostate Specific Antigen Form
Patient Initials
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Medical Record Number
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Institution Name
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Participating Group
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Study Number Participating Group
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Trial subject ID Participating Group
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Patient Description
CancerInitialDiagnosisDate
date
MedDRACode
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FirstAbnormalBoneMarrowPriorMyelodysplasticSyndromeFindingDate
date
PatientAgeValue
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Leukemia Classification (who/fab)
DiseaseDiagnosisHematopoieticType
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DiseaseDiagnosisHematopoieticSpecify
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LeukemiaFrench-American-BritishClassificationCategory
text
LeukemiaFrench-American-BritishClassificationSpecify
text
Clinical Onset Of Aml
ClinicalEtiologyAcuteMyeloidLeukemiaDiagnosisType
text
PriorTherapyMDSLeukemiaAdministeredInd-2
boolean
PriorChemotherapyMyelodysplasticSyndromeAdministeredInd-2
boolean
HydroxyureaAgentAdministeredDayCount
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Extramedullary Disease Involvement
DiseaseExtramedullaryInvolvementSite
text
DiseaseExtramedullaryInvolvementOtherSite
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LaboratoryProcedureAuerRodsOutcomeStatus
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AssessmentMethodText
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Organ Involvement
SplenomegalyPalpationDocumentedInd
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SplenomegalyImageDocumentedInd
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HepatomegalyPalpationDocumentedInd
text
HepatomegalyImageDocumentedInd
text
LymphadenopathyPalpationDocumentedInd
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LymphadenopathyImageDocumentedInd
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Current Symptoms
InfectionSeverityType
text
AdverseEventHemorrhageSymptomStatus
text
Lab Data At Study Entry
ChestX-RayResultType
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ChestX-rayResultAbnormalSpecify
text
ChestX-RayAssessmentDate
date
HepaticBilirubinLabValue
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HepaticBilirubinLabUpperLimitNormalValue
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CardiacEvaluationDiagnosticProcedure
text
AbnormalElectrocardiographyAdverseEventPresentSpecify
text
DiagnosticElectrocardiogramPerformedDate
date
HeartLVEFTestPercentageValue
float
LeftVentricularEjectionFractionAssessmentType
text
Overall Response
Person Completing Form
text
Date Form Completed
date