Description:

Radiation Therapy Oncology Group Follow-up Form Phase III Recurrent Head and Neck Study Follow-up Form Combination Chemotherapy With or Without Radiation Therapy in Treating Patients With Recurrent Head and Neck Cancer That Cannot Be Removed By Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EB74C29B-D3BF-298D-E034-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EB74C29B-D3BF-298D-E034-0003BA3F9857

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Versions (2) ▾
  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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Head and Neck Cancer NCT00113399 Follow-Up - Radiation Therapy Oncology Group Follow-up Form Phase III Recurrent Head and Neck Study Follow-up Form - 2299564v3.0

No Instruction available.

  1. StudyEvent: Radiation Therapy Oncology Group Follow-up Form Phase III Recurrent Head and Neck Study Follow-up Form
    1. No Instruction available.
Header
Amended data
PATIENT'S VITAL STATUS
PRIMARY CAUSE OF DEATH
PERFORMANCE STATUS HAS THE PATIENT HAD A DOCUMENTED CLINICAL ASSESSMENT FOR THIS CANCER SINCE SUBMISSION OF THE PREVIOUS FOLLOW-UP FORM? (ZUBROD)
HAS THE PATIENT BEEN DIAGNOSED WITH FIRST LOCAL RECURRENCE OR PROGRESSION (SINCE SUBMISSION OF THE PREVIOUS FOLLOW-UP FORM)
HAS THE PATIENT BEEN DIAGNOSED WITH FIRST REGIONAL RECURRENCE OR PROGRESSION (SINCE SUBMISSION OF THE PREVIOUS FOLLOW-UP FORM)
HAS THE PATIENT BEEN DIAGNOSED WITH FIRST DISTANT RECURRENCE OR PROGRESSION (SINCE SUBMISSION OF THE PREVIOUS FOLLOW-UP FORM)
SITE(S) OF DISTANT PROGRESSION (USE CODETABLE FROM Q8)
HAS A NEW PRIMARY CANCER OR MDS BEEN DIAGNOSED (MYELODYSPLASTIC SYNDROME SINCE SUBMISSION OF THE PREVIOUS FOLLOW-UP FORM?)
SITE(S) OF NEW PRIMARY (USE CODETABLE BELOW)
NON-PROTOCOL SURGERY
NON-PROTOCOL CHEMOTHERAPY
NON-PROTOCOL BIOLOGIC THERAPY
NON-PROTOCOL RADIATION THERAPY
OTHER NON-PROTOCOL THERAPY
NEW OR CONTINUING ADVERSE EVENTS?
DOES THE PATIENT CURRENTLY HAVE SWALLOWING PROBLEMS?
IF YES, HOW LONG HAVE SWALLOWING PROBLEMS BEEN PRESENT?
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 CTCAE 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?
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