Description:

GOG-0262: Medical History Form (Form MEDH) Paclitaxel and Carboplatin With or Without Bevacizumab in Treating Patients With Stage II, Stage III, or Stage IV Ovarian Epithelial Cancer, Primary Peritoneal Cancer, or Fallopian Tube Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6E5EB14F-2030-D8EE-E040-BB89AD4349C7

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6E5EB14F-2030-D8EE-E040-BB89AD4349C7
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Versions (4)
  1. 9/19/12 9/19/12 -
  2. 8/11/14 8/11/14 - Martin Dugas
  3. 8/11/14 8/11/14 - Martin Dugas
  4. 1/9/15 1/9/15 - Martin Dugas
Uploaded on:

January 9, 2015

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License :
Creative Commons BY-NC 3.0 Legacy
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Fallopian Tube Cancer NCT01167712 Pre-Study - GOG-0262: Medical History Form (Form MEDH) - 2917582v1.0

English
Details

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1 forms  
  1. StudyEvent: GOG-0262: Medical History Form (Form MEDH)
    1. No Instruction available.
Header Module
Ovarian: Disease Description
Have you ever been treated for hypertension that required medication
Peripheral vascular disease with claudication
Myocardial infarction or cerebrovascular accident
Have you smoked during the past year
Do you currently take medication for diabetes
Ovarian: Findings From Primary Surgery
Have you ever been diagnosed with an autoimmune disease
Ovarian: Post-operative Findings Following Primary Surgery
Have you ever had peptic ulcer disease, documented by endoscopy
Have you ever had an intestinal obstruction, documented radiographically
Have you ever had inflammatory bowel disease
If you have had inflammatory bowel disease, did you require medication and/or surgery
Have you ever had diverticulitis that required hospitalization or outpatient antibiotics and dietary modification
Have you ever had C. difficile colitis
Have you ever had small bowel resection with anastomosis
At primary debulking surgery
Have you ever had large bowel resection with anastomosis
At primary debulking surgery
Footer Module
Do you use corticosteroids for a chronic condition
Do you use NSAID chronically
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