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
Hormone Therapy Status
Start Date
Stop Date
Reason Discontinued
Continue in FU? (yes)
Drug 1
Drug 2
Drug 3
Required Frequency of follow-up?
*
Will the patient require additional testing during follow-up?
Yes
No
Testing During Follow-up
Test / Lab / Scan
Due Date
1
2
3
4
5
6
7
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