Long Term FU Request

Protocol

Long Term Follow-Up Request
Protocol ID *
Study Nurse *
Nurse Email *
example@example.com
Site CTEP ID *
Date of Request *

Month Day Year
Date
Patient Contact information
Patient ID # *
Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Alternate Contact Information
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Relationship to patient
Patient Status
Date of Last Treatment

Month Day Year
Date
Reason Treatment Ended

Completed Protocol Treatment Withdrew-Toxicities Withdrew-Disease Progression Withdrew- Patient Choice
Last Contact Date

Month Day Year
Date
Next Review Date

Month Day Year
Date
Are all queries and outstanding data completed?

Yes No
Mode of Contact
Physician the patient will see during follow-up.
Next Appointment
Will you continue to see the patient?

Yes No
Follow-Up Requirements
Is the patient receiving hormone therapy? *

Yes No

Protocol