Beschreibung:

RTOG 1010 Demographic Data Form (A5) Radiation Therapy, Paclitaxel, and Carboplatin With or Without Trastuzumab in Treating Patients With Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8666BB88-BFD1-08B9-E040-BB89AD434AC6

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8666BB88-BFD1-08B9-E040-BB89AD434AC6

Stichworte:

Ösophagustumoren

Klinische Studie [Dokumenttyp]

Demographie

Versionen (4) ▾

Hochgeladen am:

09.01.2015

DOI:

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Lizenz:

Creative Commons BY-NC 3.0 Legacy

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Adenocarcinoma of the Gastroesophageal Junction NCT01196390 Demographic - RTOG 1010 Demographic Data Form (A5) - 3085100v1.0

Details

INSTRUCTIONS: Submit this form at patient's entry on study. Complete the information by filling in boxes or blanks as requested. See separate page for instructions

StudyEvent: RTOG 1010 Demographic Data Form (A5)
1. INSTRUCTIONS: Submit this form at patient's entry on study. Complete the information by filling in boxes or blanks as requested. See separate page for instructions

Header

RTOG Study No.

Case #

Institution Name

Institution No.

Patient Initials

RTOG Patient ID

Cigarette History

Smoked at least 100 cigarette during lifetime (5 packs)

No (0)

Yes, But Quit (1)

Yes, Currently Smoke (2)

Age began smoking cigarettes

Number of years smoked cigarettes

Average number of cigarettes smoked per day

If quit, age stopped smoking completely

If you have had any of the illnesses listed below, please check yes for those that apply (check = Yes)

Heart Problems (1)

Lung Problems (2)

High Blood Pressure (3)

Bleeding Problems (4)

Circulation Problems (5)

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Beschreibung:

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Adenocarcinoma of the Gastroesophageal Junction NCT01196390 Demographic - RTOG 1010 Demographic Data Form (A5) - 3085100v1.0

INSTRUCTIONS: Submit this form at patient's entry on study. Complete the information by filling in boxes or blanks as requested. See separate page for instructions

Beschreibung:

Link:

Stichworte:

Versionen (4) ▾

Hochgeladen am:

DOI:

Lizenz:

Modell Kommentare:

Itemgroup Kommentare für:

Item Kommentare für:

Adenocarcinoma of the Gastroesophageal Junction NCT01196390 Demographic - RTOG 1010 Demographic Data Form (A5) - 3085100v1.0

INSTRUCTIONS: Submit this form at patient's entry on study. Complete the information by filling in boxes or blanks as requested. See separate page for instructions

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