Discontinue Trial Medication
Patient ID (derived)
text
Discont. of Trial Medication: Date
date
Discont. of Trial Medication: Date Status
Reason (Inv. considers...)
Reason (Unacceptable toxicity...)
Reason (HIV infection)
Reason (Patient requests discontinuation)
Reason (Patient unable or unwilling to comply...)
Reason (Other reason)
Discont. of Trial Medication: Reason Text
Discont. of Trial Medication: Date of Signature
Discont. of Trial Medication: Date of Sig. Status
Discont. of Trial Medication: Signature yes/no
Comment Discont. Trial Med.