Description:

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

Keywords:
Versions (4) ▾
  1. 8/26/12
  2. 8/11/14
  3. 1/9/15
  4. 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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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

Header
Unnamed2
Amended Data
Who completed this form (Check one box)
Patient Race Category (Check all that apply)
Patient Ethnic Group Cateogy (Check one box)
Highest school grade completed (Check one box)
Religion during childhood (Check one box)
Marital status (Check one box)
Where were you born (Check one box Check the box of the country where you were born)
Where did you live the longest (Check one box)
Cigarette History
Smoked at least 100 cigarette during lifetime (5 packs)
If you have had any of the illnesses listed below, please check yes for those that apply (check = Yes)
Family History
Are you adopted (Check one In 10C; complete the question only for your children; omit mother, father, sisters, brothers)
Blood relative with cancer (check = yes)
Type of Cancer (check = yes)
Have you ever heard of Cancer Prevention Trials (Check one box By Cancer Prevention Trials we mean studies in which healthy people, including cured cancer patients, volunteer to take part in experimental cancer prevention, such as the use of special diets and new drugs. People volunteer in order to obtain the newest prevention for themselves and to help scientists learn how well the new prevention methods work)
How likely would you be to volunteer to participate in Cancer Prevention Trials (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)