Description:

Gynecologic Procedures Form (Form 24-GYN) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B12178AE-C51B-4967-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B12178AE-C51B-4967-E034-0003BA12F5E7

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Versions (2) ▾
  1. 8/26/12
  2. 1/9/15
Uploaded on:

January 9, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Treatment - Gynecologic Procedures Form (Form 24-GYN) - 2074074v3.0

GYNECOLOGIC PROCEDURES FORM (Form 24-GYN) Instructions: Complete this form if patient had gynecologic surgery, procedures and/or diagnostic imaging (excluding PAP smears and procedures related to diagnosis of cervical carcinoma in situ). Submit with the next scheduled Follow-Up (24-E) Form. Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

Report All Gynecologic Procedures Which Apply:
Reason hysterectomy or oophorectomy was done (select all that apply by marking your selection with an ?X? in the appropriate boxes)
Pathologic Diagnosis
Ccrr Module For Gynecologic Procedures Form (form 24-gyn)

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