Description:

RTOG 0825 Phase III GBM Demographic Data Form (A5) Temozolomide and Radiation Therapy With or Without Bevacizumab in Treating Patients With Newly Diagnosed Glioblastoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5A7BB7B0-E979-2DF8-E044-0003BA3F9857

Lien:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5A7BB7B0-E979-2DF8-E044-0003BA3F9857
Mots-clés:
  1. 26/08/2012 26/08/2012 -
  2. 11/08/2014 11/08/2014 - Martin Dugas
  3. 11/08/2014 11/08/2014 - Martin Dugas
  4. 09/01/2015 09/01/2015 - Martin Dugas
  5. 09/01/2015 09/01/2015 - Martin Dugas
Téléchargé le:

9 janvier 2015

DOI:
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Creative Commons BY-NC 3.0 Legacy
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Brain and Central Nervous System Tumors NCT00884741 Demographic - RTOG 0825 Phase III GBM Demographic Data Form (A5) - 2796060v1.0

Version 2.2

  1. StudyEvent: RTOG 0825 Phase III GBM Demographic Data Form (A5)
    1. Version 2.2
Header
Unnamed2
Amended Data
Who completed this form (Check one box)
Patient Race Category (Check all that apply)
Patient Ethnic Group Cateogy (If you consider yourself multiracial, check all additional categories that apply in this question Do not include what you reported in 2A.)
Highest school grade completed (Check one box)
Religion during childhood (Check one box)
Marital status (Check one box)
Where were you born (Check one box)
Where did you live the longest (Check one box)
Cigarette History
Smoked at least 100 cigarette during lifetime (5 packs)
If you have had any of the illnesses listed below, please check yes for those that apply (check = Yes)
Family History
Are you adopted (Check one)
Blood relative with cancer (check = yes)
Type of Cancer (check = yes)
Have you ever heard of Cancer Prevention Trials (Check one box)
How likely would you be to volunteer to participate in Cancer Prevention Trials (The numbers below allow you to rate your answer between 1 - never and 10 - extremely likely. Circle the number below that best describes your choice.)

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