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CALGB 90601: Medical History Form Gemcitabine Hydrochloride and Cisplatin With or Without Bevacizumab in Treating Patients With Advanced Urinary Tract Cancer NCT00942331 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=657DC836-E20A-2DC7-E040-BB89AD437499

Länk:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=657DC836-E20A-2DC7-E040-BB89AD437499

Nyckelord:

Klinische Studie [Dokumenttyp]

Anamnesenerhebung

C67.9

Versioner (3)

2012-08-26 2012-08-26 -
2015-01-09 2015-01-09 - Martin Dugas
2015-05-18 2015-05-18 - Martin Dugas

Uppladdad den:

18 maj 2015

DOI:

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Licens :

Creative Commons BY-NC 3.0 Legacy

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Urinary Tract Cancer Medical History Form CALGB 90601 NCT00942331

Engelsk 1

Engelsk

Detaljer

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted.

1 Formulär

StudyEvent: CALGB 90601: Medical History Form
1. INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted.

Header

CALGB Form (C-1761)

CALGB Study No. (90601)

CALGB Patient ID

Are data amended

Yes

Patient Initials (Last, First, Middle)

Patient Hospital No

Institution/Affiliate

Participating Group

Participating Group Study No.

Participating Group Patient ID

Significant Medical History, Concomitant Diseases

Myocardial infarction (1 If multiple events, record date of most recent here, and the earlier ones in C-260 Remarks Addenda form.)

Yes

Date of myocardial infarction (CRF says "Date of event" MM DD YYYY)

Coronary artery by-pass graft (CABG)

No (No)

Yes (Yes)

Unknown (Unknown)

Date of CABG (CRF says "Date of event" MM DD YYYY)

Cardiac stent/angioplasty

No (No)

Yes (Yes)

Unknown (Unknown)

Date of cardiac stent/ angioplasty (CRF says "Date of event" MM DD YYYY)

Angina pectoris

No (No)

Yes (Yes)

Unknown (Unknown)

Coronary Artery Disease (heart disease)

No (No)

Yes (Yes)

Unknown (Unknown)

Congestive heart failure

No (No)

Yes (Yes)

Unknown (Unknown)

Hypertension

No (No)

Yes (Yes)

Unknown (Unknown)

Peripheral Vascular Disease

No (No)

Yes (Yes)

Unknown (Unknown)

Arterial thrombosis

No (No)

Yes (Yes)

Unknown (Unknown)

Venous thrombosis

No (No)

Yes (Yes)

Unknown (Unknown)

Transient ischemic disease

No (No)

Yes (Yes)

Unknown (Unknown)

Cerebrovascular accident (including stroke)

No (No)

Yes (Yes)

Unknown (Unknown)

Subarachnoid hemorrhage

No (No)

Yes (Yes)

Unknown (Unknown)

Date of event

Dementia

No (No)

Yes (Yes)

Unknown (Unknown)

Chronic pulmonary disease

No (No)

Yes (Yes)

Unknown (Unknown)

Connective tissue disease

No (No)

Yes (Yes)

Unknown (Unknown)

Arthritis

No (No)

Yes (Yes)

Unknown (Unknown)

Peptic ulcer disease

No (No)

Yes (Yes)

Unknown (Unknown)

Mild liver disease

No (No)

Yes (Yes)

Unknown (Unknown)

Diabetes (without complications)

No (No)

Yes (Yes)

Unknown (Unknown)

Diabetes with end organ disease

No (No)

Yes (Yes)

Unknown (Unknown)

Hemiplegia

No (No)

Yes (Yes)

Unknown (Unknown)

Renal Disease

No (NO)

Yes (YES)

Unknown (UNKNOWN)

Diverticulitis

No (No)

Unknown (Unknown)

Yes (Yes)

Prior Therapy

Prior chemotherapy?

Yes

Current bisphosphonate therapy?

Yes

specify date started (If Yes,)

Prior surgery for prostate cancer? (Mark all that apply with an X.)

Prostatectomy (Prostatectomy)

Pelvic Lymphadenectomy (Pelvic lymphadenectomy)

Transurethral Resection Of The Prostate (Transurethral resection of the prostate)

Prostate Biopsy (Prostate biopsy)

Radical prostatectomy, specify date completed (mm dd yyyy)

Pelvic lymphadenectomy, specify date completed (mm dd yyyy)

Prior radiation therapy? (Mark all that apply with an X.)

No Prior Radiation Therapy (No prior radiation therapy)

Prostate External Beam Radiation Therapy (Prostate external beam radiation therapy)

Prostate Bed External Beam Radiation Therapy After Radical Prostatectomy (Prostate bed external beam radiation therapy after radical prostatectomy)

Prostate Implants (Prostate implants)

Radioisotope Therapy (Radioisotope therapy)

Palliative Radiotherapy (Palliative radiotherapy)

Total dose administered (cGy)

Radiation therapy start date (mm dd yyyy)

Radiation therapy end date (mm dd yyyy)

Neoadjuvant hormonal therapy prior to surgery? (prostatectomy)

Yes

Neoadjuvant hormonal therapy prior to radiation? (for prostate cancer)

Yes

Neoadjuvant hormonal therapy start date (mm dd yyyy)

Neoadjuvant hormonal therapy end date (mm dd yyyy)

Adjuvant hormonal therapy after surgery? (prostatectomy)

Yes

Adjuvant hormonal therapy after radiation? (for prostate cancer)

Yes

Adjuvant hormonal therapy start date (MM DD YYYY)

Adjuvant hormonal therapy end date (MM DD YYYY)

Current type of gonadal suppression (Mark all that apply with an X.)

Orchiectomy (Orchiectomy)

Lhrh Agonist (LHRH agonist)

Date of orchiectomy (specify MM DD YYYY)

LHRH agonist start date (MM DD YYYY)

LHRH agonist end date (MM DD YYYY)

LHRH agonist treatment type (Mark one with an X.)

Continuous (Continuous)

Intermittent (Intermittent)

Hormonal Agent (For each hormonal agent listed below, record whether the agent was administered 0=not taken; 1=initial; 2=second line; 3=third line; 99=other reason. If administered, record agent start and end dates.)

Aminoglutethimide (Aminoglutethimide)

Bicalutamide (Bicalutamide)

Finasteride (Finasteride)

Flutamide (Flutamide)

4 fler Item i detaljvyn.

Other specify

Agent administered status (For each hormonal agent listed below, record whether the agent was administered 0=not taken; 1=initial; 2=second line; 3=third line; 99=other reason.)

Not Taken (not taken)

Initial (initial)

Second Line (second line)

Third Line (third line)

Other (Other reason)

Agent start date (mm/dd/yyyy)

Agent end date (mm/dd/yyyy)

Any other prior therapy?

Yes

Other Prior Regimen Name

Other prior therapy start date (MM DD YYYY)

Other prior therapy end date (MM DD YYYY)

Background Information

What is the highest grade you finished in school? (Mark one with an X.)

1-8 Grades (1-8 grades)

9-11 Grades (9-11 grades)

High School Graduate (High School graduate)

Some College (Some college)

4 fler Item i detaljvyn.

What is your marital status? (Mark one with an X.)

Single, Never Married (Single, never married)

Married (Married)

Separated (Separated)

Divorced (Divorced)

Widowed (Widowed)

What is your current employment status? (Mark one with an X.)

Employed 32 Hours Or More Per Week (Employed 32 hours or more per week)

Employed Less Than 32 Hours Per (Employed less than 32 hours per week)

Full-time Student (Full-time student)

Part-time Student (Part-time student)

6 fler Item i detaljvyn.

Other, specify

Completed by (Last name, First name)

Date form completed (mm dd yyyy)

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Versioner (3)

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Urinary Tract Cancer Medical History Form CALGB 90601 NCT00942331

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted.

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