Description:

Head and Neck Cancers - Follow Up Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D49693D6-CE22-5E44-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=D49693D6-CE22-5E44-E034-0003BA12F5E7

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  1. 9/19/12
  2. 1/9/15
Uploaded on:

January 9, 2015

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Creative Commons BY-NC 3.0 Legacy
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Follow-Up - Head and Neck Cancers - Follow Up Form - 2268620v3.0

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  1. StudyEvent: Head and Neck Cancers - Follow Up Form
    1. No Instruction available.
Crf Header
Head & Neck: Vital Status
Patient's Vital Status
Primary Cause of Death
Is the patient off study (and further follow-up evaluations will not be completed)
Off Study Reason (If yes,)
Head & Neck: Disease Follow-up Status
Has the patient had a documented clinical assessment for this cancer? (since submission of the previous follow-up form?)
Head & Neck: Notice Of Progression
Has the patient developed a first progression (or relapse) that has not been previously reported?
Has the patient been diagnosed with first local-regional recurrence (or progression?)
Site of First Local-Regional Progression (s mark all that apply)
Has the patient been diagnosed with first distant recurrence/progression?
Site of First Distant Progression (s mark all that apply)
Head & Neck: Notice Of New Primary
Has a new primary cancer or MDS been diagnosed that has not been previously reported? (myelodysplastic syndrome)
Is this a Second primary in the Upper Aero-digestive Tract? (If yes,)
Head & Neck: New Adverse Events
Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >=3), long term toxicity that has not been previously reported
Head & Neck: Long-term Functional Assessment
Does the patient currently have swallowing problems?
How long have swallowing problems been present? (If yes,)
Does the patient currently require tube feeding?
Is patient dependent on tube feeding for >50% of nutritional support? (If yes,)
Was a feeding tube inserted during this reporting period? (including CTC event dysphagia >= grade 3)
Was a feeding tube discontinued during this reporting period?
Was a tracheostomy performed during this reporting period? (e.g., for breathing difficulty)
Was use of a tracheostomy discontinued during this reporting period?
Normalcy of Diet Rating (Ask the patient what kinds of foods are difficult for him/her to eat. Begin at the low end of the scale. Move up the scale, giving examples of foods in each category and asking patient if s/he can eat those food items. The patient's score is the highest )
Public Eating Rating (Ask the patient where s/he eats, with whom s/he eats, and whether s/he alters his/her diet according to where s/he is eating. Choose the score that best fits the patient.)
Understandability of Speech Rating (Score based on the interviewer's ability to understand the patient during conversation. Choose the score that best fits the patient.)
Head & Neck: Off-protocol Treatment
Was any off-protocol therapy given after completion of protocol treatment?
Off-Protocol Surgery
Off-Protocol Chemotherapy
Off-Protocol Immunotherapy
Off-Protocol Radiation Therapy
Off-Protocol Complementary and Alternative Medications (CAM)
Other Off-Protocol Therapy

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