Description:

E5103 Hypertension Status Form Doxorubicin, Cyclophosphamide, and Paclitaxel With or Without Bevacizumab in Treating Patients With Lymph Node-Positive or High-Risk, Lymph Node-Negative Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3AE22206-73CD-059C-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3AE22206-73CD-059C-E044-0003BA3F9857

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Versions (4) ▾
  1. 8/26/12
  2. 8/8/14
  3. 12/16/14
  4. 1/8/15
Uploaded on:

January 8, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00433511 Follow-Up - E5103 Hypertension Status Form - 2683669v1.0

INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule).

General information
Unnamed Module 4
On Treatment Report Period
Off Treatment Report Period
Anti-Hypertensive Drugs (Please mark each agent administered this cycle For Baseline, indicate agents administered in the last 21 days)
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