Follow-Up - Head and Neck Cancers - Follow Up Form - 2268620v3.0 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 Head & Neck: Notice Of New Primary 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 
