Header
Birth Date
date
Patient Hospital No
text
Institution Name
Institution Number
Investigator Name
Disease Recurrence
Assessment Date
MetastasisDiagnosisDate
Loco-regional Recurrence
BreastCarcinomaLocal-RegionalRecurrentDiseaseAnatomicSite
Evaluation method
Evaluation method, specify
Distant Metastasis
BreastMalignantNeoplasmMetastaticInvolvementSite
Metastatic Sites, other
Comments
Investigator Signature Date
Investigator Signature