NSABP Worksheet for Pregnancy Event Form Combination Chemotherapy in Treating Women Who Have Undergone Surgery for Node-Positive Breast Cancer Source Form: NCI FormBuilder:



  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
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January 9, 2015


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Breast Cancer NCT00093795 Pathology - NSABP Worksheet for Pregnancy Event Form - 3006894v1.0

This paper worksheet may be completed to facilitate the entry of the pregnancy event information in NSABP Coordinator Online. Please complete if a patient or the sexual partner of an NSABP patient becomes pregnant during study therapy or within 6 months of completing study therapy. A follow-up report may be necessary to report the pregnancy outcome (e.g., normal baby, birth defect). Partially completed online forms may be saved in Coordinator Online.

Unnamed 1
Cancer Treatment Prior To Pregnancy Diagnosis
Classification of NSABP Protocol Patient
Tests & Procedures Relevant To Pregnancy
Has the patient had any tests or procedures performed relevant to pregnancy
Result of test
Pregnancy Information
Pregnancy prevention measures
Pregnancy Status/pregnancy Outcome
Pregnancy Status
Pregnancy Outcome
Fetal/baby Outcome
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