Description:

PACCT-1 TAILORx FACT - Endocrine Symptoms Form NCT00310180 Hormone Therapy With or Without Combination Chemotherapy in Treating Women Who Have Undergone Surgery for Node-Negative Breast Cancer (The TAILORx Trial) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=84B85E26-3D9D-5248-E040-BB89AD43122A

Lien:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=84B85E26-3D9D-5248-E040-BB89AD43122A
Mots-clés:
  1. 26/08/2012 26/08/2012 -
  2. 08/01/2015 08/01/2015 - Martin Dugas
  3. 08/06/2015 08/06/2015 -
Téléchargé le:

8 juin 2015

DOI:
Pour une demande vous connecter.
Licence :
Creative Commons BY-NC 3.0 Legacy
Modèle Commentaires :

Ici, vous pouvez faire des commentaires sur le modèle. À partir des bulles de texte, vous pouvez laisser des commentaires spécifiques sur les groupes Item et les Item.

Groupe Item commentaires pour :

Item commentaires pour :

Vous devez être connecté pour pouvoir télécharger des formulaires. Veuillez vous connecter ou s’inscrire gratuitement.

PACCT-1 TAILORx FACT - Endocrine Symptoms Form NCT00310180

INSTRUCTIONS: Please complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center. Keep a copy for your files. Please submit form to the address below: ECOG Coordinating Center Attn: Data, 900 Commonwealth Ave, 2nd Floor, Boston, MA, 02215

Header
Report Period on Treatment
Report Period (since start of Step 2 Choose one)
Data amendment
Are data amended
Assessment Date
Additional Concerns
I have hot flashes
I have cold sweats
I have night sweats
I have vaginal discharge
I have vaginal itching/irritation
I have vaginal bleeding or spotting
I have vaginal dryness
I have pain or discomfort with intercourse
I have lost interest in sex.
I have gained weight
I feel lightheaded (dizzy).
I have been vomiting
I have diarrhea
I get headaches
I feel bloated
I have breast sensitivity/tenderness
I have mood swings
I am irritable
I have pain in my joints

Similar models

Utilisez ce formulaire pour les retours, les questions et les améliorations suggérées.

Les champs marqués d’un * sont obligatoires.

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