E1305 On-Study Form NCT00588770 Chemotherapy With or Without Bevacizumab in Treating Patients With Recurrent or Metastatic Head and Neck Cancer Source Form: NCI FormBuilder:

  1. 8/11/14 8/11/14 - Martin Dugas
  2. 8/11/14 8/11/14 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
  4. 6/16/15 6/16/15 -
  5. 9/20/21 9/20/21 -
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September 20, 2021

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License :
Creative Commons BY-NC 3.0 Legacy
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E1305 On-Study Form NCT00588770

INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center within one week of patient¿s entry on study. Keep a copy for your files.

Reporting Period
Data amendment
Patient Information
ECOG Performance Status (at study entry)
Weight Loss in Previous Six Months
Prior Radiation Therapy to head and neck
Prior Radiation Therapy to other sites
Planned Chemotherapy Regimen
Smoking History
Does the patient currently smoke
Does the patient currently consume alcohol
Average Alcohol Consumption (NOTE: 1 drink = 1 oz. whiskey = 12 oz. beer)
Urine Dipstick Result
Patient History
Does the patient have a history of thromboembolic events (arterial)
Has the patient suffered cardiovascular disease?
Myocardial infarction
Stable Angina
Unstable angina
Hypertension history
Prior Treatment For Disease
Prior Induction or Adjuvant Chemotherapy
Prior systemic therapy (as part of curative therapy) (Provide an answer for all)
Prior Surgery
Head & Neck: Disease Description
Histologic Grade
Primary Site (Select region category bolded only if specific site is unknown or there are > 1 specific sites)
Disease Description
Disease Status
Primary disease status
Regional Lymph Node Status (Local/)
Distant lymph nodes
Mediatstinal lymph nodes
Soft tissue
Other visceral
Baseline Abnormalities
CTC Adverse Event Grade

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