SCCO Medical History Form

Protocol: hcunliffe10-032
PRIVILEGED COMMUNICATION FOR INVESTIGATIONAL USE ONLY
MEDICAL HISTORY FORM
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Form Completed By
SCCO Patient
Family Member (please specify relationship)
______________________________
Date Completed: _____/______/_________
MM DD YYYY
At date of completion of this form, patient is: Alive Deceased date of death _____/_____/_____
MM DD YYYY
1. Symptoms prior to diagnosis of SCCO
1a. First diagnosed with Small Cell Carcinoma of the Ovary (SCCO)
Date of diagnosis _____/______/_________ Patient Age at Diagnosis _________
MM DD YYYY
1b. Describe the physical symptoms experienced prior to diagnosis of SCCO (check all the apply)
A swollen or bloated abdomen
Pressure or pain in the abdomen
Pressure or pain in pelvis
Pressure or pain in the back or legs
Shortness of breath
Excessive fatigue
Unusual vaginal bleeding
Urinary symptoms (increased urgency and frequency)
Difficulty with eating or feeling full quickly
Nausea
Vomiting
Gas
Constipation
Indigestion
Other. Explain: _____________________________________________________________________
Other. Explain: _____________________________________________________________________
Other. Explain: _____________________________________________________________________
1c. How long did patient experience some or all of these symptoms before diagnosis ____ yrs____ months
2. Patient History of Cancer
2a. Was there a diagnosis and treatment for any other type of cancer before diagnosis of SCCO
No Go to question 2b
Unsure Go to question 2b
Yes complete below: (Check here and use reverse for more space.)
Type: _______________________ Date: ______/_____/_________
MM DD YYYY
Details: _______________________________________________________________________________
continued on next page
Type: _______________________ Date: ______/_____/_________
MM DD YYYY
© TGen BOCRU 2006 Page 1 of 8 Version - 11/23/2010

Protocol: hcunliffe10-032
PRIVILEGED COMMUNICATION FOR INVESTIGATIONAL USE ONLY
MEDICAL HISTORY FORM
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Details: _______________________________________________________________________________
Comments: _______________________________________________________________________________
_________________________________________________________________________________________
2b. Was a genetic test performed to determine whether patient had an abnormality in either the BRCA1 gene or
the BRCA2 gene
No Go to question 2c
Unknown Go to question 2c
Yes Check here if BRCA1 mutation test was positive
Check here if BRCA2 mutation test was positive
2c. Were other genetic or DNA tests performed to evaluate possible genetic alterations for this patient
No Go to question 3
Unknown Go to question 3
Yes Explain: (Check here and use reverse for more space.)_______________________
__________________________________________________________________________________
3. Patient Family History of Cancer (First-Degree Relatives)
3. Do any of the patient’s first-degree relatives, for example, parents, siblings, or children have a history of
cancer of any kind Yes No Unknown
If yes, complete all below.
(Check here and use reverse for more space.)
Relative 1: _______________ Cancer type: ___________________ Age at Diagnosis if known: _____
Details: _______________________________________________________________________________
_____________________________________________________________________________________
Relative 2: ______________ Cancer type: ___________________ Age at Diagnosis if known: _____
Details: _______________________________________________________________________________
_____________________________________________________________________________________
Relative 3: _______________ Cancer type: ___________________ Age at Diagnosis if known: _____
Details: _______________________________________________________________________________
_____________________________________________________________________________________
Check here if additional first-degree relatives have a history of cancer and use reverse. Continued on next page.
4. Patient Family History of Cancer (Second-Degree Relatives)
© TGen BOCRU 2006 Page 2 of 8 Version - 11/23/2010

Protocol: hcunliffe10-032
PRIVILEGED COMMUNICATION FOR INVESTIGATIONAL USE ONLY
MEDICAL HISTORY FORM
Barcode:
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4. Do any of the patient’s second-degree relatives, for example, grandparents, aunts, uncles, or cousins, have a
history of cancer Yes No Unknown
If yes, complete below: (Check here and use reverse for more space.)
Relative 1: ____________
Maternal
Paternal Cancer type: ______________ Age at Diagnosis if known: ____
Details: _______________________________________________________________________________
_____________________________________________________________________________________
Maternal
Relative 2: ______________ Paternal Cancer type: ______________ Age at Diagnosis if known: ____
Details: _______________________________________________________________________________
_____________________________________________________________________________________
Maternal
Relative 3: ______________ Paternal Cancer type: _______________ Age at Diagnosis if known: ____
Details: _______________________________________________________________________________
_____________________________________________________________________________________
Maternal
Relative 4: ______________ Paternal Cancer type: _______________ Age at Diagnosis if known: ____
Details: _______________________________________________________________________________
_____________________________________________________________________________________
Check here if additional second-degree relatives have a history of cancer and use reverse.
5. Risk Factors - Hormonal
5a. What was the patient’s age at her first period (Menarche) ________ Unknown
5b. Was patient pregnant at any time
No Go to question 5c
Unknown Go to question 5c
Yes How many pregnancies ________ Unknown
Patient age at first pregnancy ________ Unknown
How many children did patient give birth to ________ Unknown
How many miscarriages or abortions did patient have ________ Unknown
continued on next page
5c. What was patient’s menopausal status at time of diagnosis of SCCO: Unknown Unsure
© TGen BOCRU 2006 Page 3 of 8 Version - 11/23/2010

Protocol: hcunliffe10-032
PRIVILEGED COMMUNICATION FOR INVESTIGATIONAL USE ONLY
MEDICAL HISTORY FORM
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Pre-pubescent
Pre-menopausal
Peri-menopausal
Post-menopausal
Menstruation not yet started. No menopausal symptoms.
No menopausal symptoms
Going through menopause* (see below for common symptoms)
Menopausal symptoms have finished.
*Common symptoms of going through menopause (the beginning of menopausal symptoms typically occur in women ages
45-55 but some women show symptoms in their 30s.
• Changes in pattern of periods (can be shorter or longer, lighter or heavier, more or less time between periods)
• Hot flashes (sudden rush of heat in upper body)
• Night sweats (hot flashes that happen while you sleep), often followed by a chill
• Trouble sleeping through the night (with or without night sweats)
• Mood changes. Irritability. Trouble focusing, feeling mixed-up or confused,
• Hair loss or thinning on your head. More hair growth on your face
• Vaginal dryness.
5d. Did patient use contraceptives for birth control at any time
No Go to question 6
Unknown Go to question 6
Yes Did patient use hormonal contraceptives Y N Unknown
Does patient currently use hormonal contraceptives Y N Unknown
Did patient stop using hormonal contraceptives 10 or
more years ago Y N Unknown
5e. List any names or types and duration of contraceptives you recall were used by patient:
Type Used Previously Currently Use Total Use in Years or Months
Oral (“the pill”) ____ Years ____ Months Unknown
IUD (“Mirena/Progestin”) ____ Years ____ Months Unknown
IUD (“Paraguard/Copper”) ____ Years ____ Months Unknown
Implant (“Implanon”) ____ Years ____ Months Unknown
Skin patch (“Ortho Evra”) ____ Years ____ Months Unknown
Injection (“Depo-Provera”) ____ Years ____ Months Unknown
Vaginal ring (“NuvaRing”) ____ Years ____ Months Unknown
Other: _________________ ____ Years ____ Months Unknown
If known, names: _______________________________________________________________________
6. Risk Factors – Lifestyle
6a. Did patient gain weight since turning 18 years of age and before diagnosis of SCCO
No Go to question 6b
Unknown Go to question 6b
Yes What was the amount of weight gain (in pounds)
0-15 16-30 31-50 More than 50 Unknown
continued on next page
6b. At the time of diagnosis, did patient smoke
© TGen BOCRU 2006 Page 4 of 8 Version - 11/23/2010

Protocol: hcunliffe10-032
PRIVILEGED COMMUNICATION FOR INVESTIGATIONAL USE ONLY
MEDICAL HISTORY FORM
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Unknown Go to question 6c
Yes How many packs per week ___ Unknown
How long did patient smoke for ___ Months or ___ Years Unknown
No
Did patient smoke at any time previously
No Go to question 6c.
Yes How long ago did patient quit ___ Months or ___ Years Unknown
How long did patient smoke for ___ Months or ___ Years Unknown
How many packs per week ___ Unknown
6c. At the time of diagnosis, did patient drink alcohol
No Go to question 7
Unknown Go to question 7
Yes Average number of drinks: _____ per Day Week Unknown
Month Year
7. Risk Factors – Other
7a. Did patient at any time have a diagnosis of one of the following (check all that apply).
Human papillomavirus (HPV)
Hepatitis B Virus (HBV)
Hepatitis C Virus (HBV)
Epsein-Barr Virus (EBV)
Human T-lymphotropic Virus (HTLV) Kaposi's sarcoma-associated herpesvirus (KSHV)
Merkel cell polyomavirus (MCPV) None I am aware of.
7b. List all possible vaccinations you can recall for this patient and approximate year if known.
Vaccine: _________________________
Vaccine: _________________________
Vaccine: _________________________
Vaccine: _________________________
year _______
year _______
year _______
year _______
Check here and list additional vaccine information on reverse.
7b. Are there any unusual environmental exposures for the patient you would like to include
For example, exposure to nuclear fallout or significant levels of radiation, work with toxic/carcinogenic
substances, exposure to unusual pathogens, etc.
Describe: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Check here if additional details on environmental exposures and use reverse.
continued on next page
© TGen BOCRU 2006 Page 5 of 8 Version - 11/23/2010

Protocol: hcunliffe10-032
PRIVILEGED COMMUNICATION FOR INVESTIGATIONAL USE ONLY
MEDICAL HISTORY FORM
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8. Treatment
8a. Did patient have surgery to remove the ovarian cancer
No
Did patient receive chemotherapy or any other treatments to shrink the cancer
No Go to Question 8e.
Yes Go to Question 8c.
Yes Date of Surgery (MM/DD/YYYY): ______/______/_______
Name of Doctor: __________________________________________
Hospital or clinic name: ____________________________________
Is a copy of the pathology report available Y N
Is a copy of the cytology report available Y N Report not ordered
Note: TGen will require a de-identified copy of the patient’s final pathology report(s) and cytology report (if
cytology was requested by the surgeon). Patient personal identifying information can either be blanked out by
you, or the TGen Research Coordinator will do this for you before it reaches the Researchers for this study.
8b. What chemotherapy did patient receive (check all that apply): Weeks Cycles
Paclitaxel (taxane, taxol) _____ _____
Cisplatin (cisplatinum, or cis-diamminedichloroplatinum(II) or CDDP) _____ _____
Carboplatin _____ _____
Cyclophosphamide (Endoxan, Cytoxan, Neosar, Procytox, Revimmune) _____ _____
Bleomycin (Blenoxane, Bleocip) _____ _____
Doxorubicin (Adriamycin, hydroxydaunorubicin). _____ _____
Etoposide (Eposin, Etopophos, Vepesid, VP-1) _____ _____
Vinblastine (vincristine) _____ _____
Unsure _____ _____
Other________________________________ _____ _____
Other________________________________ _____ _____
Not applicable
Additional details: (Check here and use reverse for more space.)______________________________
Date chemotherapy started : _____/______/_______ Unknown
MM DD YYYY
Date chemotherapy completed: _____/______/_______ Unknown
MM DD YYYY
continued on next page
© TGen BOCRU 2006 Page 6 of 8 Version - 11/23/2010

Protocol: hcunliffe10-032
PRIVILEGED COMMUNICATION FOR INVESTIGATIONAL USE ONLY
MEDICAL HISTORY FORM
Barcode:
Barcode will be completed by TGen
8c. Was there a diagnosis of ‘hypercalcemia’ Hypercalcemia is a high level of calcium in the blood.
Y N Unknown
If yes, did hypercalcemia symptoms (typically nausea and / or vomiting) lessen or disappear following
surgery Y N Unknown
Not Applicable
8d. Is (or was) patient receiving any other kind of treatment other than surgery and chemotherapy (like
radiation)
No Go to question 8e
Unsure Go to question 8e
Yes Please explain, including dates of treatment: (Check here and use reverse for more space.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
8e. Is (or was) patient receiving any other prescribed medications as part of her care
Yes
complete below. (Check here and use reverse for more space.)
No
Go to question 8f
Unknown
Go to question 8f
Prefer not to answer Go to question 8f
Drug Name Indication # months
Comments: _______________________________________________________________________________
_________________________________________________________________________________________
continued on next page
© TGen BOCRU 2006 Page 7 of 8 Version - 11/23/2010

Protocol: hcunliffe10-032
PRIVILEGED COMMUNICATION FOR INVESTIGATIONAL USE ONLY
MEDICAL HISTORY FORM
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8f. Is (or was) patient diagnosed with any other medical conditions or co-morbidities (examples listed below)
Myocardial infarct Congestive heart disease Peripheral vascular disease Hemiplegia
Cerebrovascular disease Chronic pulmonary disease Moderate or severe renal disease AIDS
Connective tissue disease Diabetes type 1 or type 2 Diabetes with end organ damage type 1 or type 2 Lymphoma
Mild liver disease Moderate or severe liver disease Any tumor (not ovarian cancer) Leukemia
Ulcer disease
Dementia
Yes complete below. (Check here and use reverse for more space.) No Unknown NA
Medical Condition
Date of Diagnosis
Comments: _______________________________________________________________________________
_________________________________________________________________________________________
Data Collection Form Receiving - To be completed by TGen staff:
Copy received at TGen by: _________________________________________ Date: ______/______/______
Name (Printed) MM DD YYYY
Comments: _______________________________________________________________________________
© TGen BOCRU 2006 Page 8 of 8 Version - 11/23/2010