Description:

Breast Cancer - Adjuvant Follow-Up Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=DA188C45-CBCA-04EA-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=DA188C45-CBCA-04EA-E034-0003BA12F5E7

Keywords:
Versions (3) ▾
  1. 9/19/12
  2. 1/9/15
  3. 1/9/15
Uploaded on:

January 9, 2015

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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Follow-Up - Breast Cancer - Adjuvant Follow-Up Form - 2279997v3.0

No Instruction available.

  1. StudyEvent: Breast Cancer - Adjuvant Follow-Up Form
    1. No Instruction available.
Crf Header
Breast: Form Administration
Are data amended? (If data are amended, please circle in red when using paper form)
Breast: Vital Status
Patient Vital Status
Primary Cause of Death (check one)
Breast: Disease Follow-up Status
Has the patient had a documented clinical assessment for this cancer? (since submission of the previous follow-up form)
Breast: Notice Of Progression - Adjuvant
Has the patient been diagnosed with first local-regional recurrence (since submission of last follow-up form)
Site of First Local-Regional Progression (s mark all that apply)
Has the patient been diagnosed with first distant recurrence/progression? (since submission of last follow-up form)
How was this progression information obtained?
How was this progression information obtained?
Breast: Notice Of New Primary
Has a new primary cancer or MDS been diagnosed that has not been previously reported? (myelodysplastic syndrome)
Breast: Long-term Toxicity
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
Breast: Long-term Therapy
Did this patient receive any tamoxifen?
Is the patient still receiving tamoxifen?
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