Description:

Chronic Myelogenous Leukemia (CML) - Follow-Up Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1AB0C43D-1393-07D0-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1AB0C43D-1393-07D0-E044-0003BA3F9857

Keywords:
Versions (2) ▾
  1. 9/19/12
  2. 1/8/15
Uploaded on:

January 8, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Follow-Up - Chronic Myelogenous Leukemia (CML) - Follow-Up Form - 2019375v3.0

No Instruction available.

  1. StudyEvent: Chronic Myelogenous Leukemia (CML) - Follow-Up Form
    1. No Instruction available.
Crf Header
Leukemia/mds: Form Administration
Are data amended (If data are amended, please circle in red when using paper form)
Aml/all/apl: Vital Status
Patient's Vital Status
Primary Cause of Death (if dead check one)
Aml/all/apl: Disease Follow-up Status
Has the patient had a documented clinical assessment for this cancer? (during this reporting period)
Did the patient achieve a complete response according to clinical/ hematologic criteria (during this reporting period)
Cml:disease Follow-up Status-cytogenetic/molecular
Has the patient had a documented cytogenetic or molecular assessment (including Philadelphia chromosome karotype or BCR-abl) (during this reporting period)
Did the patient achieve a complete response according to cytogenetic or molecular criteria (during this reporting period)
Was cytogenetic analysis successful? (If yes, indicate the results of cytogenetic or molecular assessment.)
Karyotypic Philadelphia Chromosome Positive
Were FISH studies performed
Specific Abnormalities Detected by FISH
Result of FISH
RT-PCR Marker Type
Result of RT-PCR for Chimeric Genes (Polymerase Chain Reaction)
Cml: Notice Of Progression - Clinical/hematologic
Has the patient developed clinical or hematologic evidence of progression or relapse (during this reporting period)
Indicate the CML classification at the time of clinical/ hematologic progression (If yes,)
Cml:disease Follow-up Status-cytogenetic/molecular
Has the patient developed cytogenetic or molecular evidence of progression or relapse (during this reporting period)
Was cytogenetic analysis successful? (If yes, indicate the results of cytogenetic or molecular assessment.)
Karyotypic Philadelphia Chromosome Positive
Were FISH studies performed
Specific Abnormalities Detected by FISH
Result of FISH
RT-PCR Marker Type
Result of RT-PCR for Chimeric Genes (Polymerase Chain Reaction)
Allows Documentation Of Any Additional Cooments

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