ID

9118

Descrizione

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

collegamento

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

Keywords

  1. 27/08/12 27/08/12 -
  2. 09/01/15 09/01/15 - Martin Dugas
Caricato su

9 gennaio 2015

DOI

Per favore, per richiedere un accesso.

Licenza

Creative Commons BY-NC 3.0 Legacy

Commenti del modello :

Puoi commentare il modello dati qui. Tramite i fumetti nei gruppi di articoli e articoli è possibile aggiungere commenti a quelli in modo specifico.

Commenti del gruppo di articoli per :

Commenti dell'articolo per :

Per scaricare i modelli di dati devi essere registrato. Per favore accesso o registrati GRATIS.

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
Descrizione

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.)
Descrizione

IndicatewhichchemopreventionagentsthepatientreceivedBEFOREDIAGNOSISandindicatethenumberofmonthspatientreceivedtheseagents.

Tipo di dati

text

Other, specify (therapy)
Descrizione

AgentName

Tipo di dati

text

Other, specify (therapy)
Descrizione

AgentName

Tipo di dati

text

MONTHS
Descrizione

MONTHS

Tipo di dati

text

DATE STOPPED (If continuing, use -1)
Descrizione

AgentEndDate

Tipo di dati

date

Prior Chemotherapy Regimen For Breast Cancer
Descrizione

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.)
Descrizione

Didpatientreceiveadjuvantand/orneoadjuvantchemotherapyforbreastcancer?

Tipo di dati

text

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

PriorChemotherapyBeginDate

Tipo di dati

date

Other, specify (therapy)
Descrizione

AgentName

Tipo di dati

text

Other, specify (therapy)
Descrizione

AgentName

Tipo di dati

text

Other, specify (therapy)
Descrizione

AgentName

Tipo di dati

text

Neoadjuvant Total Number of Cycles
Descrizione

AgentCountCoursesAdministered

Tipo di dati

float

Neoadjuvant Total Number of Cycles
Descrizione

AgentCountCoursesAdministered

Tipo di dati

float

DATE STOPPED (If continuing, use -1)
Descrizione

AgentEndDate

Tipo di dati

date

Agent Dose
Descrizione

AgentTotalDose

Tipo di dati

float

Agent Dose
Descrizione

AgentTotalDose

Tipo di dati

float

Route
Descrizione

AgentAdminRoute

Tipo di dati

text

Other SERM, (specify)
Descrizione

OtherSERM,

Tipo di dati

text

DATE STARTED (D M Y)
Descrizione

AgentBeginDate

Tipo di dati

date

Investigator/Designee Signature
Descrizione

InvestigatorSignature

Tipo di dati

text

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

InvestigatorSignatureDate

Tipo di dati

date

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

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

Patient ID Number (Study No.)
Descrizione

PatientStudyID,CoordinatingGroup

Tipo di dati

text

Patient Initials (f m fl sl)
Descrizione

Patient Initials

Tipo di dati

text

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

PatientBirthDate

Tipo di dati

date

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

MainMemberInstitution/Affiliate

Tipo di dati

text

Center Code (Ver.#1)
Descrizione

ParticipatingGroupCode

Tipo di dati

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
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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)

Si prega di utilizzare questo modulo per feedback, domande e suggerimenti per miglioramenti.

I campi contrassegnati da * sono obbligatori.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial