ID

9118

Description

Prior Treatment History Form (Form 24-H) 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=B1274765-836E-53AF-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B1274765-836E-53AF-E034-0003BA12F5E7

Keywords

  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer NCT00659373 Pre-Study - Prior Treatment History Form (Form 24-H) - 2074666v3.0

PRIOR TREATMENT HISTORY FORM (Form 24-H) Instructions: This form collects data on treatment of breast cancer prior to randomization. Please submit within one (1) month of randomization. Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

Before Diagnosis: Chemoprevention For Breast Cancer
Description

Before Diagnosis: Chemoprevention For Breast Cancer

Indicate which chemoprevention agents the patient received BEFORE DIAGNOSIS and indicate the number of months patient received these agents. (select all that apply by marking an ?X? in the appropriate Therapy.)
Description

IndicatewhichchemopreventionagentsthepatientreceivedBEFOREDIAGNOSISandindicatethenumberofmonthspatientreceivedtheseagents.

Data type

text

Other, specify (therapy)
Description

AgentName

Data type

text

Other, specify (therapy)
Description

AgentName

Data type

text

MONTHS
Description

MONTHS

Data type

text

DATE STOPPED (If continuing, use -1)
Description

AgentEndDate

Data type

date

Prior Chemotherapy Regimen For Breast Cancer
Description

Prior Chemotherapy Regimen For Breast Cancer

Did patient receive adjuvant and/or neoadjuvant chemotherapy for breast cancer? (Mark your selection with an ?X? in the appropriate boxes.)
Description

Didpatientreceiveadjuvantand/orneoadjuvantchemotherapyforbreastcancer?

Data type

text

Date of first dose of chemotherapy (day month year)
Description

PriorChemotherapyBeginDate

Data type

date

Other, specify (therapy)
Description

AgentName

Data type

text

Other, specify (therapy)
Description

AgentName

Data type

text

Other, specify (therapy)
Description

AgentName

Data type

text

Neoadjuvant Total Number of Cycles
Description

AgentCountCoursesAdministered

Data type

float

Neoadjuvant Total Number of Cycles
Description

AgentCountCoursesAdministered

Data type

float

DATE STOPPED (If continuing, use -1)
Description

AgentEndDate

Data type

date

Agent Dose
Description

AgentTotalDose

Data type

float

Agent Dose
Description

AgentTotalDose

Data type

float

Route
Description

AgentAdminRoute

Data type

text

Other SERM, (specify)
Description

OtherSERM,

Data type

text

DATE STARTED (D M Y)
Description

AgentBeginDate

Data type

date

Investigator/Designee Signature
Description

InvestigatorSignature

Data type

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date (day month year)
Description

InvestigatorSignatureDate

Data type

date

Ccrr Module For Prior Treatment History Form (form 24-h)
Description

Ccrr Module For Prior Treatment History Form (form 24-h)

Patient ID Number (Study No.)
Description

PatientStudyID,CoordinatingGroup

Data type

text

Patient Initials (f m fl sl)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient's Date of Birth (day)
Description

PatientBirthDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
Participating Center/Affiliate
Description

MainMemberInstitution/Affiliate

Data type

text

Center Code (Ver.#1)
Description

ParticipatingGroupCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701

Similar models

PRIOR TREATMENT HISTORY FORM (Form 24-H) Instructions: This form collects data on treatment of breast cancer prior to randomization. Please submit within one (1) month of randomization. Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Before Diagnosis: Chemoprevention For Breast Cancer
IndicatewhichchemopreventionagentsthepatientreceivedBEFOREDIAGNOSISandindicatethenumberofmonthspatientreceivedtheseagents.
Item
Indicate which chemoprevention agents the patient received BEFORE DIAGNOSIS and indicate the number of months patient received these agents. (select all that apply by marking an ?X? in the appropriate Therapy.)
text
AgentName
Item
Other, specify (therapy)
text
AgentName
Item
Other, specify (therapy)
text
MONTHS
Item
MONTHS
text
AgentEndDate
Item
DATE STOPPED (If continuing, use -1)
date
Item Group
Prior Chemotherapy Regimen For Breast Cancer
Item
Did patient receive adjuvant and/or neoadjuvant chemotherapy for breast cancer? (Mark your selection with an ?X? in the appropriate boxes.)
text
Code List
Did patient receive adjuvant and/or neoadjuvant chemotherapy for breast cancer? (Mark your selection with an ?X? in the appropriate boxes.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Neoadjuvant Only (Neoadjuvant only)
CL Item
Adjuvant Only (Adjuvant only)
CL Item
Both Adjuvant And Neoadjuvant (Both adjuvant and neoadjuvant)
PriorChemotherapyBeginDate
Item
Date of first dose of chemotherapy (day month year)
date
AgentName
Item
Other, specify (therapy)
text
AgentName
Item
Other, specify (therapy)
text
AgentName
Item
Other, specify (therapy)
text
AgentCountCoursesAdministered
Item
Neoadjuvant Total Number of Cycles
float
AgentCountCoursesAdministered
Item
Neoadjuvant Total Number of Cycles
float
AgentEndDate
Item
DATE STOPPED (If continuing, use -1)
date
AgentTotalDose
Item
Agent Dose
float
AgentTotalDose
Item
Agent Dose
float
AgentAdminRoute
Item
Route
text
OtherSERM,
Item
Other SERM, (specify)
text
AgentBeginDate
Item
DATE STARTED (D M Y)
date
InvestigatorSignature
Item
Investigator/Designee Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date (day month year)
date
Item Group
Ccrr Module For Prior Treatment History Form (form 24-h)
PatientStudyID,CoordinatingGroup
Item
Patient ID Number (Study No.)
text
Patient Initials
Item
Patient Initials (f m fl sl)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PatientBirthDate
Item
Patient's Date of Birth (day)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
MainMemberInstitution/Affiliate
Item
Participating Center/Affiliate
text
ParticipatingGroupCode
Item
Center Code (Ver.#1)
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)

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