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