Re-Admission/HospitalizationForm (ADM)

Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Re
Admi
s
si
on/
Hos
pi
t
al
i
z
at
i
onFor
m(
ADM)
WebVer
si
on:1.
0;4.
07;052416
Segment(
PROTSEG)
:
Dat
eofAdmi
ssi
on(
ADMI
TDT)
:
1.Dat
eofdi
s
char
ge:
(
DI
SCHDT)
2.Pat
i
entdi
s
char
ges
t
at
us:
(
DI
SCPTST)
(
mm/
dd/
y
yyy
)
1-Al
i
v
e
2-Dead
I
fDead,aDeat
hFor
m mustbesubmi
t
t
ed.
3.Rec
or
dPRI
MARYdi
sc
har
gedi
agnosi
s
:
(
PHSPREAS)
?
*
Spec
i
f
yor
gan:
(
ADM4SPEC)
*
*
Speci
f
yot
her
:
(
ADM1SPEC)
4.Rec
or
dsecondar
ydi
schar
gedi
agnos
es:
a.GVHD:
(
REASGVHD)
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
b.Rel
apse/
pr
ogr
es
si
on:
(
REASRLPS)
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
c.Gr
af
tf
ai
l
ur
e:
(
REASGF)
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
d.I
nf
ec
t
i
on:
(
REASI
NF)
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
e.Fever
:
(
REASFVR)
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
f
.Sei
z
ur
e:
(
REASSZR)
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
g.Bl
eedi
ng/
hemor
r
hage:
(
REASGI
BL)
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
h.Di
ar
r
hea:
(
REASDRH)
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
1-Cont
r
i
but
or
y
2-Noncont
r
i
but
or
y
i
.Naus
ea/
vomi
t
i
ng:
(
REASNV)
j
.Or
ganf
ai
l
ur
e:
(
REASORGF)
Spec
i
f
yor
gan:
(
ADM3SPEC)
k.Tr
auma:
(
REASTRAM)
l
.Ps
ychi
at
r
i
c:
(
REASPSYC)
m.Secondar
ymal
i
gnancy:
(
REASMALG)
n.Sc
hedul
edpr
ocedur
e/
t
r
eat
ment
:
(
REASPROC)
o.Thr
ombosi
s
/
t
hr
ombus/
embol
i
sm:
(
REASTRMB)
p.Ot
her
:
(
REASOTHR)
Spec
i
f
yot
her
:
(
ADM2SPEC)
5.Rec
or
dr
eadmi
s
si
oni
nst
i
t
ut
i
on:
(
ADMCENTR)
Comment
s:
(
ADMCOMM1)
?
Addi
t
i
ona
lSel
ect
i
onOpt
i
onsf
orADM
Recor
dPRI
MARYdi
schar
gedi
agnosi
s:
06-NonFungalI
nf
ec
t
i
on
07-Fever
08-Sei
z
ur
e
09-Bl
eedi
ng/
Hemor
r
hage
10-Di
ar
r
hea
11-Nausea/
Vomi
t
i
ng
12-Or
ganFai
l
ur
e(
speci
f
yor
gan)
*
13-Tr
auma
14-Psyc
hi
at
r
i
c
15-Secondar
yMal
i
gnancy
16-Tr
ans
pl
ant
17-Schedul
edPr
ocedur
e/
Tr
eat
ment
18-Thr
ombosi
s/
Thr
ombus/
Embol
i
sm
99-Ot
her(
speci
f
y
)
*
*
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Adv
er
seEventFor
m(
AE1
)
WebVer
si
on:1.
0;5.
00;012816
Segment(
PROTSEG)
:
Dat
eofOnset(
ADVDATE)
:
Eventdescr
i
pt
i
on(
ADVENT)
:
1.Repor
tac
t
i
vat
i
ons
t
at
us:
(
AVSTATUS)
?
I
fOt
her
,speci
f
yr
easonf
ordeact
i
vat
i
on:
(
AESPEC1)
2.Rec
or
ddat
et
r
ans
pl
antcent
erbecameawar
eoft
heev
ent
:
(
AVAWARDT)
(
mm/
dd/
yy
yy)
3.I
ndi
cat
ewei
ghtatt
i
meoft
heev
ent
:
(
AVWGHTKG)
4.Wast
hi
seventex
pec
t
edorant
i
ci
pat
ed?(
AVEXPECT)
(
xxx
.
x) k
g
1-Yes
?
2-No
5.Rec
or
dt
hesever
i
t
yofev
ent
:
(
AVEVENT)
?
6.Whati
st
her
el
at
i
onshi
pt
ost
udyt
her
apy
/
i
nt
er
vent
i
on:
(
AVRELAT)
7.I
st
her
eanal
t
er
nat
i
veet
i
ol
ogy
:
(
AVETI
OL)
8.Whati
st
heef
f
ectons
t
udyt
her
apy/
i
nt
er
vent
i
ons
chedul
e:
(
AVEFFECT)
9.Rec
or
dt
hemos
ts
ever
eout
comeoft
heev
ent
:
(
AVOUTCOM)
?
10.Rec
or
dt
hedat
eofr
es
ol
ut
i
on:
(
AVRESDT)
(
mm/
dd/
yy
yy) ?
11.Wast
hi
seventass
oc
i
at
edwi
t
h:
(
AVASSOCI
)
?
Comment
s:
(
AE1COMM)
Addi
t
i
ona
lSel
ect
i
onOpt
i
onsf
orAE1
Wast
hi
seventassoci
at
edwi
t
h:
5-Requi
r
edI
nt
er
v
ent
i
ont
oPr
eventPer
manentI
mpai
r
mentorDamage
6-Hos
pi
t
al
i
z
at
i
on(
I
ni
t
i
alorPr
ol
onged)
9-Ot
herSAE
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
AESummar
yFor
m(
AE2)
WebVer
si
on:1.
0;3.
12;101615
Segment(
PROTSEG)
:
Dat
eofOnset(
ADVDATE)
:
Eventdescr
i
pt
i
on(
ADVENT)
:
1.Repor
tact
i
vat
i
onst
at
us
:
(
AVSTAT_A)
Rel
evantPastMedi
calHi
st
or
y
2.Doest
hepat
i
enthav
eanyr
el
ev
anthi
st
or
y,i
ncl
udi
ngpr
eex
i
st
i
ngmedi
c
al
c
ondi
t
i
ons?(
SEMEDHXS)
1-Yes
2-No
I
fYes
,i
nc
l
udeanyr
el
evanthi
st
or
y
,i
ncl
udi
ngpr
eexi
s
t
i
ngmedi
calc
ondi
t
i
onsbel
ow.
(
SEMEDHX)
3.EventSummar
y
I
ncl
udecl
i
ni
calhi
st
or
yofevent
,as
soci
at
eds
i
gnsandsympt
oms,al
t
er
nat
i
v
eet
i
ol
ogi
esbei
ngconsi
der
edandmedi
calmanagementbel
ow.
(
SESUMM)
4.I
ni
t
i
al
submi
t
t
er
:
(
SEI
SUBBY)
Name:
Dat
e:
(
SEI
SUBDT)
Name:
Dat
e:
(
SEASUBDT)
/
yy
yy)
5.Aut
hor
i
z
edsubmi
t
t
er
:
(
SEASUBBY)
/
yy
yy) ?
(
mm/
dd
(
mm/
dd
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
AETher
apyFor
m(
AE3)
WebVer
si
on:1.
0;4.
05;101615
Segment(
PROTSEG)
:
Dat
eofOnset(
ADVDATE)
:
Eventdescr
i
pt
i
on(
ADVENT)
:
1.Repor
tact
i
vat
i
onst
at
us
:
(
AVSTAT_B)
St
udyPr
oduct
/
Suspe
ctMedi
ca
t
i
onDa
t
a
2.Wast
hepat
i
entr
ec
ei
v
i
nganyst
udypr
oduct
s/
s
uspec
tmedi
cat
i
ons?(
RCVSP)
1-Yes
I
fYes
,l
i
stt
hest
udypr
oduct
/
suspectmedi
cat
i
onst
hesubj
ectwast
aki
ngi
nt
hegr
i
dbel
ow.
St
udyPr
oductName
(
Not
e:I
fbl
i
nded,i
ndi
cat
e
assuch)
Doseof
St
udyPr
oduct
(
s)
atSAEOnset
Rout
eof
St
udyPr
oduct
(
s
)
atSAEOnset
2-No
Schedul
eof
St
udyPr
oduc
t
(
s)
atSAEOns
et
Dat
eSt
udy
Pr
oduct
Fi
r
s
tSt
ar
t
ed
(
mm/
dd/
yyyy
)
Dat
eSt
udy
Pr
oduc
t
Las
tTaken
(
mm/
dd/
yy
yy)
Reasonf
orUse
(
SPNAME1)
(
SP1DOSE)
(
SP1ROUTE)
(
SP1SCHED)
(
SP1STDT)
(
SP1SPDT)
(
SP1REASO)
(
SPNAME2)
(
SP2DOSE)
(
SP2ROUTE)
(
SP2SCHED)
(
SP2STDT)
(
SP2SPDT)
(
SP2REASO)
(
SPNAME3)
(
SP3DOSE)
(
SP3ROUTE)
(
SP3SCHED)
(
SP3STDT)
(
SP3SPDT)
(
SP3REASO)
(
SPNAME4)
(
SP4DOSE)
(
SP4ROUTE)
(
SP4SCHED)
(
SP4STDT)
(
SP4SPDT)
(
SP4REASO)
(
SPNAME5)
(
SP5DOSE)
(
SP5ROUTE)
(
SP5SCHED)
(
SP5STDT)
(
SP5SPDT)
(
SP5REASO)
Conc
omi
t
antMedi
cat
i
ons
3.Wast
hepat
i
entt
aki
nganyc
onc
omi
t
antmedi
cat
i
ons?(
RCVCONMD)
1-Yes
2-No
I
fYes
,l
i
stt
heconc
omi
t
antmedi
cat
i
onst
hepat
i
entwast
ak
i
ngupt
o1mont
hpr
i
ort
oSAEonseti
nt
hegr
i
dbel
ow.
Medi
cat
i
on
St
ar
tDat
e
(
mm/
dd/
y
yyy
)
St
opDat
e
(
mm/
dd/
yy
yy)
Dose,Rout
e,Sc
hedul
e
I
ndi
cat
i
on
(
CONMED1)
(
CM1STDT)
(
CM1SPDT)
(
CM1DOSE)
(
CM1I
NDI
C)
(
CONMED2)
(
CM2STDT)
(
CM2SPDT)
(
CM2DOSE)
(
CM2I
NDI
C)
(
CONMED3)
(
CM3STDT)
(
CM3SPDT)
(
CM3DOSE)
(
CM3I
NDI
C)
(
CONMED4)
(
CM4STDT)
(
CM4SPDT)
(
CM4DOSE)
(
CM4I
NDI
C)
(
CONMED5)
(
CM5STDT)
(
CM5SPDT)
(
CM5DOSE)
(
CM5I
NDI
C)
(
CONMED6)
(
CM6STDT)
(
CM6SPDT)
(
CM6DOSE)
(
CM6I
NDI
C)
(
CONMED7)
(
CM7STDT)
(
CM7SPDT)
(
CM7DOSE)
(
CM7I
NDI
C)
(
CONMED8)
(
CM8STDT)
(
CM8SPDT)
(
CM8DOSE)
(
CM8I
NDI
C)
(
CONMED9)
(
CM9STDT)
(
CM9SPDT)
(
CM9DOSE)
(
CM9I
NDI
C)
(
CONMED10)
(
CM10STDT)
(
CM10SPDT)
(
CM10DOSE)
(
CM10I
NDI
)
(
CONMED11)
(
CM11STDT)
(
CM11SPDT)
(
CM11DOSE)
(
CM11I
NDI
)
(
CONMED12)
(
CM12STDT)
(
CM12SPDT)
(
CM12DOSE)
(
CM12I
NDI
)
(
CONMED13)
(
CM13STDT)
(
CM13SPDT)
(
CM13DOSE)
(
CM13I
NDI
)
(
CONMED14)
(
CM14STDT)
(
CM14SPDT)
(
CM14DOSE)
(
CM14I
NDI
)
(
CONMED15)
(
CM15STDT)
(
CM15SPDT)
(
CM15DOSE)
(
CM15I
NDI
)
(
CONMED16)
(
CM16STDT)
(
CM16SPDT)
(
CM16DOSE)
(
CM16I
NDI
)
(
CONMED17)
(
CM17STDT)
(
CM17SPDT)
(
CM17DOSE)
(
CM17I
NDI
)
(
CONMED18)
(
CM18STDT)
(
CM18SPDT)
(
CM18DOSE)
(
CM18I
NDI
)
(
CONMED19)
(
CM19STDT)
(
CM19SPDT)
(
CM19DOSE)
(
CM19I
NDI
)
(
CONMED20)
(
CM20STDT)
(
CM20SPDT)
(
CM20DOSE)
(
CM20I
NDI
)
(
CONMED21)
(
CM21STDT)
(
CM21SPDT)
(
CM21DOSE)
(
CM21I
NDI
)
(
CONMED22)
(
CM22STDT)
(
CM22SPDT)
(
CM22DOSE)
(
CM22I
NDI
)
(
CONMED23)
(
CM23STDT)
(
CM23SPDT)
(
CM23DOSE)
(
CM23I
NDI
)
(
CONMED24)
(
CM24STDT)
(
CM24SPDT)
(
CM24DOSE)
(
CM24I
NDI
)
(
CONMED25)
(
CM25STDT)
(
CM25SPDT)
(
CM25DOSE)
(
CM25I
NDI
)
Comment
s:
(
AE3COMM)
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
AELabor
at
or
y/
Di
agnost
i
csFor
m(
AE4)
WebVer
si
on:1.
0;3.
11;101615
Segment(
PROTSEG)
:
Dat
eofOnset(
ADVDATE)
:
Eventdescr
i
pt
i
on(
ADVENT)
:
1.Repor
tact
i
vat
i
onst
at
us
:
(
AVSTAT_C)
Labor
a
t
or
yTestResul
t
s
2.Wer
er
el
evantl
abor
at
or
yt
es
t
sper
f
or
med?(
LABTSTPF)
1-Yes
I
fYes
,r
ecor
dt
her
el
ev
antl
abor
at
or
yt
es
tr
es
ul
t
si
nt
hegi
r
dbel
ow.
Tes
t
Col
l
ect
i
onDat
e
(
mm/
dd/
yy
yy)
Resul
t
(
I
nc
l
udeuni
t
s)
2-No
Si
t
eNor
mal
Range
(
I
ncl
udeuni
t
s)
LabVal
uePr
evi
ous
t
ot
hi
sSAE
(
I
nc
l
udeuni
t
s
)
Col
l
ect
i
onDat
e
f
orPr
ev
i
ousLab
(
mm/
dd/
y
yyy)
(
ADLTST1)
(
ADL1CD)
(
ADL1RES)
(
ADL1NORG)
(
ADL1PRVL)
(
ADL1PCD)
(
ADLTST2)
(
ADL2CD)
(
ADL2RES)
(
ADL2NORG)
(
ADL2PRVL)
(
ADL2PCD)
(
ADLTST3)
(
ADL3CD)
(
ADL3RES)
(
ADL3NORG)
(
ADL3PRVL)
(
ADL3PCD)
(
ADLTST4)
(
ADL4CD)
(
ADL4RES)
(
ADL4NORG)
(
ADL4PRVL)
(
ADL4PCD)
(
ADLTST5)
(
ADL5CD)
(
ADL5RES)
(
ADL5NORG)
(
ADL5PRVL)
(
ADL5PCD)
(
ADLTST6)
(
ADL6CD)
(
ADL6RES)
(
ADL6NORG)
(
ADL6PRVL)
(
ADL6PCD)
(
ADLTST7)
(
ADL7CD)
(
ADL7RES)
(
ADL7NORG)
(
ADL7PRVL)
(
ADL7PCD)
(
ADLTST8)
(
ADL8CD)
(
ADL8RES)
(
ADL8NORG)
(
ADL8PRVL)
(
ADL8PCD)
(
ADLTST9)
(
ADL9CD)
(
ADL9RES)
(
ADL9NORG)
(
ADL9PRVL)
(
ADL9PCD)
(
ADLTST10)
(
ADL10CD)
(
ADL10RES)
(
ADL10NRG)
(
ADL10PVL)
(
ADL10PCD)
Di
agnost
i
cTe
st
s(
EX:MR,CTSc
an,Ul
t
r
asound)
3.Wer
er
el
evantdi
agnos
t
i
ct
est
sper
f
or
med?(
DXSTPF)
1-Yes
2-No
I
fYes
,r
ecor
dt
her
el
ev
antdi
agnos
t
i
ct
es
tr
esul
t
si
nt
hegr
i
dbel
ow.Submi
tc
opi
esoft
hedi
agnost
i
ct
esti
favai
l
abl
e.
Test
(
ADDTS1)
Dat
ePer
f
or
med
(
mm/
dd/
yy
yy)
Resul
t
s/
Comment
s
(
AD1DTDAT)
(
AD1DTRES)
(
ADDTS2)
(
AD2DTDAT)
(
AD2DTRES)
(
ADDTS3)
(
AD3DTDAT)
(
AD3DTRES)
(
ADDTS4)
(
AD4DTDAT)
(
AD4DTRES)
(
ADDTS5)
(
AD5DTDAT)
(
AD5DTRES)
(
ADDTS6)
(
AD6DTDAT)
(
AD6DTRES)
(
ADDTS7)
(
AD7DTDAT)
(
AD7DTRES)
(
ADDTS8)
(
AD8DTDAT)
(
AD8DTRES)
(
ADDTS9)
(
AD9DTDAT)
(
AD9DTRES)
(
ADDTS10)
(
AD10DTDT)
(
AD10DTRS)
Comment
s:
(
AE4COMM)
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
AERev
i
e
w For
m(
AE5
)
WebVer
si
on:1.
0;3.
12;101615
Segment(
PROTSEG)
:
Dat
eofOnset(
ADVDATE)
:
Eventdescr
i
pt
i
on(
ADVENT)
:
1.Repor
tact
i
vat
i
onst
at
us
:
(
AVSTAT_D)
2.Rev
i
ewed:
(
AEREVI
EW)
1-Yes
2-No
3.Rev
i
ewedby:
(
ARFREVBY)
4.Rev
i
ew dat
e:
(
ARFREVDT)
5.Comment1-ForDi
s
t
r
i
but
i
on:
(
ARCM1DI
S)
6.Comment2-Al
lOt
herRev
i
ewer
s/
Dat
aCoor
di
nat
i
ngCent
er
(
ARCM2ALL)
(
mm/
dd/
y
yyy
)
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
AEMe
di
calMoni
t
orRevi
ewe
rFor
m(
AE6)
WebVer
si
on:1.
0;8.
00;012816
Segment(
PROTSEG)
:
Dat
eofOnset(
ADVDATE)
:
Eventdescr
i
pt
i
on(
ADVENT)
:
1.Adver
seevents
t
at
us:
(
AVSTAT_E)
2.Hast
hi
seventbeendet
er
mi
nedt
obeanunex
pec
t
ed,gr
ade35adv
er
s
eevent
?
(
AMDETER)
1-Yes
2-No
3.Doest
hi
sr
equi
r
eex
pedi
t
edr
epor
t
i
ngt
ot
heDSMB?(
AMEXPDSM)
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
4.Doyour
ecommendt
hepat
i
entbewi
t
hdr
awnf
r
om f
ur
t
herpr
ot
ocol
t
her
apy?
(
AMWI
THDR)
5.I
st
her
evi
ewcompl
et
e?(
AMREVDNE)
6.I
fNo,whataddi
t
i
onali
nf
or
mat
i
oni
sr
equi
r
ed:
(
AMREVI
NF)
7.Medi
cal
Moni
t
oreventdescr
i
pt
i
on:
(
AMMMEVDS)
8.Medi
cal
Moni
t
orCTCAEgr
adeofevent
:
(
CTCAEGRD)
Comment
s:
(
AE6COMM)
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Base
l
i
neFor
m -0
801(
BL4)
WebVer
si
on:1.
0;2.
01;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Pr
et
r
anspl
antSt
at
us
Compl
et
et
hef
ol
l
owi
ngquest
i
onsr
egar
di
ngt
hepat
i
ent
'
spr
et
r
anspl
antst
at
us
.
1.Pat
i
ent
'
spr
i
mar
ydi
agnosi
spr
et
r
anspl
ant
:
(
PM0801DX)
2.I
fAML,r
ec
or
dt
hedi
seasest
at
uspr
et
r
anspl
ant
:
(
AML801SG)
3.I
fALL,r
ecor
dt
hedi
s
easest
at
uspr
et
r
ans
pl
ant
:
(
ALL801SG)
4.I
fCML,r
ec
or
dt
hedi
seasest
at
uspr
et
r
anspl
ant
:
(
CML801SG)
5.I
fOt
herLeukemi
a,s
pec
i
f
ypr
i
mar
ydi
agnosi
spr
et
r
ans
pl
ant
:
(
BL4OTLEU)
6.I
fOt
herLeukemi
a,r
ecor
ddi
seases
t
at
uspr
et
r
anspl
ant
:
(
BL4OTLKD)
7.I
fMDS,r
ec
or
dt
hedi
seas
est
at
uspr
et
r
anspl
ant
:
(
MDS801SG)
8.I
fMul
t
i
pl
eMyel
oma/
PCD,r
ec
or
dt
hedi
seasest
at
uspr
et
r
anspl
ant
:
(
BL4MMST)
9.I
fLy
mphoma,r
ecor
dt
hedi
seases
t
at
uspr
et
r
anspl
ant
:
(
LYM801SG)
10.I
fOt
her
,speci
f
ypr
i
mar
ydi
agnosi
spr
et
r
anspl
ant
:
(
OPRI
MDI
A)
11.I
fOt
her
,r
ecor
dt
hedi
seases
t
at
uspr
et
r
anspl
ant
:
(
ODI
SESG)
12.Rec
or
dt
het
y
peofcondi
t
i
oni
ngr
egi
men:
(
CON0801R)
1-Myel
oabl
at
i
v
e
2-Nonmyel
oabl
at
i
veorReduc
edI
nt
ens
i
t
y
Tr
ans
pl
ant
Compl
et
et
hef
ol
l
owi
ngquest
i
onsr
egar
di
ngt
hepat
i
ent
st
r
anspl
antst
at
us.
13.Dat
eoft
r
ans
pl
ant
:
(
T0801DT)
(
mm/
dd/
yyy
y)
14.Pat
i
ent
'
sCMVs
t
at
usatt
r
anspl
ant
:
(
CMV0801S)
15.St
em c
el
l
t
ype:
(
T0801TY)
Donor1
16.Sour
c
e:
(
REL0801U)
1-Rel
at
ed
17.Dat
eofbi
r
t
h:
(
BL4DRBDT)
18.Gender
:
(
BL4DRGEN)
2-Unr
el
at
ed
(
mm/
dd/
yyy
y)
1-Mal
e
2-Femal
e
19.CMVs
t
at
us:
(
BL4D1CMV)
20.HLATypi
ngMet
hod:
(
HLA801RE)
21.Rec
or
dy
ouri
ns
t
i
t
ut
i
onsHLAmat
c
hscor
ef
ort
hi
spat
i
ent
:
(
HLA0801S)
22.Wast
hes
t
em cel
lpr
oduc
tTCel
ldepl
et
ed?(
T0801CEL)
23.Whatwast
het
ot
al
nucl
eat
edc
el
l
dos
e?(
BL4D1TNC)
1-Yes
2-No
(
xx
.
x) X10^
7NC/
kg
Donor2
24.Gender
:
(
BL4SDGEN)
1-Mal
e
2-Femal
e
25.HLATypi
ngMet
hod:
(
BL4D2HLT)
26.Rec
or
dy
ouri
ns
t
i
t
ut
i
onsHLAmat
c
hscor
ef
ort
hi
spat
i
ent
:
(
BL4D2HLM)
27.Whatwast
het
ot
al
nucl
eat
edc
el
l
dos
e?(
BL4D2TNC)
(
xx
.
x) X10^
7NC/
kg
GVHD Hi
s
t
or
y
Pr
ophyl
axi
s
28.Di
dt
hepat
i
entr
ecei
veGVHD pr
ophy
l
ax
i
spos
tt
r
ans
pl
ant
?(
BL4GVHPR)
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
I
ndi
cat
eanyi
mmunosuppr
ess
ant(
pr
ophyl
axi
s
)r
ec
ei
ved:
29.Cy
cl
ospor
i
ne:
(
BL4CYCLO)
30.Tacr
ol
i
mus:
(
BL4TACRO)
31.Si
r
ol
i
mus:
(
BL4SI
RO)
32.Cor
t
i
c
ost
er
oi
ds
:
(
BL4CORTI
)
33.Met
hot
r
ex
at
e:
(
BL4METHO)
34.MMF:
(
BL4PRMMF)
35.ATG (
t
hy
mogl
obul
i
n)orATGAM (
equi
ne)
:
(
BL4PRATG)
36.Cy
t
ox
an(
cyc
l
ophosphami
de)
:
(
BL4PRCYT)
37.Ot
her
(
BL4PROT)
38.Spec
i
f
yot
her
:
(
BL4PROSP)
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
Acut
eGVHD
39.Di
dt
hepat
i
enthaveAcut
eGVHDpr
i
ort
oenr
ol
l
i
ngi
nt
hi
ss
t
udy?(
BL4PREV)
40.Dat
eofdi
agnos
i
sofAcut
eGVHD:
(
AGVH801D)
1-Yes
2-No
(
mm/
dd/
yyy
y)
41.Max
i
mumov
er
al
lgr
adeofAcut
eGVHD:
(
AGVH801O)
42.Max
i
mumski
nabnor
mal
i
t
i
es:
(
AGVHSKGR)
43.Max
i
mumupperGIabnor
mal
i
t
i
es:
(
AGVHUGI
)
44.Max
i
muml
owerGI
abnor
mal
i
t
i
es:
(
AGVHLGI
)
45.Max
i
muml
i
v
erabnor
mal
i
t
i
es
:
(
AGVHLVGR)
Acut
eGVHDTr
eat
ment
I
ndi
cat
ei
fanyoft
hef
ol
l
owi
nghavebeengi
vent
ot
hepat
i
entf
orAcut
eGVHD t
r
eat
mentpr
i
ort
oenr
ol
l
menti
nt
hi
sst
udy
.
46.Pr
edni
sone:
(
BL4PRED)
1-Yes
2-No
47.Si
r
ol
i
mus:
(
BL4TRSI
R)
1-Yes
2-No
48.Met
hy
l
pr
edni
sone:
(
BL4METHY)
1-Yes
2-No
49.MMF:
(
BL4MMF)
1-Yes
2-No
50.MMF/
pl
acebo(
BMTCTN 0802st
udydr
ug)
:
(
BL4TRMPL)
1-Yes
2-No
51.I
nf
l
i
x
i
mab:
(
BL4I
NFLX)
1-Yes
2-No
52.Dac
l
uz
i
mab:
(
BL4DACLM)
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
53.Pent
ost
at
i
n:
(
BL4PENT)
54.Et
aner
cept
:
(
BL4ETAN)
55.Ont
ak:
(
BL4ONTAK)
56.Ski
nt
opi
c
al
st
er
oi
ds:
(
BL4STS)
57.Nonabsor
bedor
alst
er
oi
ds(
e.
g.
,
Budes
oni
de,Ent
oc
or
t
)
:
(
BL4ORST)
58.Ex
t
r
acor
por
ealPhot
opher
esi
s:
(
BL4ECP)
59.ATG (
t
hy
mogl
obul
i
n)orATGAM (
equi
ne)
:
(
BL4TRATG)
60.Ot
her
:
(
BL4OTHTR)
61.Spec
i
f
yot
her
:
(
BL4OTHSP)
62.Comment
s:
(
B0801COM)
Addi
t
i
ona
lSel
ect
i
onOpt
i
onsf
orBL4
Pat
i
ent
'
spr
i
mar
ydi
agnosi
spr
et
r
anspl
ant
:
06-My
el
odyspl
ast
i
c(
MDS)
/Myel
opr
ol
i
f
er
at
i
v
e(
MPS)Di
sor
der
s
07-Mul
t
i
pl
eMy
el
oma/Pl
asmaCel
lDi
s
or
der(
PCD)
08-NonHodgk
i
nLymphoma
09-Hodgki
nLymphoma
10-Sol
i
dTumor
s
11-Sever
eApl
as
t
i
cAnemi
a
12-I
nher
i
t
edAbnor
mal
i
t
i
esofEr
y
t
hr
ocyt
eDi
f
f
er
ent
i
at
i
onorFunc
t
i
on
13-Di
sor
der
soft
heI
mmuneSys
t
em
14-I
nher
i
t
edAbnor
mal
i
t
i
esofPl
at
el
et
s
15-I
nher
i
t
edDi
sor
der
sofMet
abol
i
sm
16-Hi
st
i
ocyt
i
cDi
s
or
der
s
17-Aut
oi
mmuneDi
sor
der
s
99-Ot
herDi
sease
I
fAML,r
ecor
dt
hedi
seasest
at
uspr
et
r
anspl
ant
:
6-Thi
r
dorSubsequentCompl
et
eRemi
ssi
on
7-Thi
r
dorSubsequentRel
apse
8-Pr
evi
ous
l
yUnt
r
eat
ed
I
fMDS,r
ecor
dt
hedi
seasest
at
uspr
et
r
anspl
ant
:
6-Ref
r
ac
t
or
yAnemi
awi
t
hExc
es
sBl
ast
s-2(
1020% bl
as
t
s)
7-My
el
odys
pl
ast
i
cSy
ndr
ome,Uncl
ass
i
f
i
ed
8-MDSAss
oc
i
at
edwi
t
hI
sol
at
edDel
(
5q)
I
fMul
t
i
pl
eMyel
oma/
PCD,r
ecor
dt
hedi
seasest
at
uspr
et
r
anspl
ant
:
06-St
abl
eDi
sease(
SD)
07-Pr
ogr
ess
i
v
eDi
sease
08-Rel
apsef
r
om CR
I
fLymphoma,r
ecor
dt
hedi
seasest
at
uspr
et
r
anspl
ant
:
6-Gr
eat
erThanSecondRel
apse
HLATypi
ngMet
hod:
6-LociA,B:Ser
ol
ogi
c,Loc
usDRB1:Hi
ghLevelDNA
7-LociA,B,C:Low LevelDNA,Loc
usDRB1:Hi
ghLevelDNA
8-LociA,B,C,DQ:LowLevelDNA,LocusDRB1:Hi
ghLev
elDNA
Recor
dyouri
nst
i
t
ut
i
onsHLAmat
chscor
ef
ort
hi
spat
i
ent
:
4/
8
5/
8
6/
8
7/
8
8/
8
3/
10
4/
10
5/
10
6/
10
7/
10
8/
10
9/
10
10/
10
Maxi
mum l
owerGIabnor
mal
i
t
i
es:
5-Sever
eAbdomi
nalPai
nwi
t
horwi
t
houtI
l
eus,orSt
oolwi
t
hFr
ankBl
oodorMel
ena
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
CI
BMTR Reci
pi
entI
D(
CI
D)
WebVer
si
on:1.
0;1.
06;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
1.CRI
D #(
CI
BMTRReci
pi
entI
D)
:
(
CRI
DNM)
Comment
s:
(
CI
DCOMM)
(
xxx
xxxx
xxx
)
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Demogr
aphi
cs(
DEM)
WebVer
si
on:1.
0;6.
02;120215
1.NameCode:
(
NAMECODE)
2.I
UBMI
D#(
i
favai
l
abl
e)
:
(
I
UBMI
D)
3.Gender
:
(
GENDER)
4.Dat
eofBi
r
t
h:
(
DOB)
5.Et
hni
ci
t
y:
(
ETHNI
C)
6.Rac
e:
(
RACE)
Speci
f
yr
ace:
(
RACESP)
7.Secondar
yRace:
(
RACE2)
Speci
f
ys
ec
ondar
yr
ace:
(
RACE2SP)
Comment
s:
(
DEMCOMM1)
1-Mal
e
2-Femal
e
(
mm/
dd/
yy
yy)
Addi
t
i
ona
lSel
ect
i
onOpt
i
onsf
orDEM
Race:
15-Sout
horCent
r
alAmer
i
can
16-East
er
nEur
opean
17-Nor
t
her
nEur
opean
18-West
er
nEur
opean
81-Whi
t
eCar
i
bbean
82-Nor
t
hCoas
tofAf
r
i
c
a
83-Mi
ddl
eEas
t
er
n
Bl
ac
k
20-Bl
ac
k(
NotOt
her
wi
seSpeci
f
i
ed)
21-Af
r
i
c
anAmer
i
c
an
22-Af
r
i
c
anBl
ac
k(
Bot
hPar
ent
sBor
ni
nAf
r
i
ca)
23-Car
i
bbeanBl
ack
24-Sout
horCent
r
alAmer
i
canBl
ac
k
29-Bl
ac
k,Ot
herSpeci
f
y
Asi
an
30-As
i
an(
NotOt
her
wi
seSpeci
f
i
ed)
31-I
ndi
an/
Sout
hAsi
an
32-Fi
l
i
pi
no(
Pi
l
i
pi
no)
34-Japanes
e
35-Kor
ean
36-Chi
nese
37-Ot
herSout
heastAs
i
an
38-Vi
et
names
e
Amer
i
c
anI
ndi
anorAl
ask
aNat
i
v
e
50-Nat
i
v
eAmer
i
c
an(
NotOt
her
wi
seSpeci
f
i
ed)
51-Nat
i
v
eAl
askan/
Esk
i
mo/
Al
eut
52-Amer
i
canI
ndi
an(
NotOt
her
wi
seSpec
i
f
i
ed)
53-Nor
t
hAmer
i
canI
ndi
an
54-Sout
horCent
r
alAmer
i
canI
ndi
an
55-Car
i
bbeanI
ndi
an
Nat
i
veHawai
i
anorOt
herPaci
f
i
cI
sl
ander
60-Nat
i
v
ePac
i
f
i
cI
sl
ander(
NotOt
her
wi
seSpec
i
f
i
ed)
61-Guamani
an
62-Hawai
i
an
63-Samoan
Ot
her
88-Unknown
90-Ot
her
,Speci
f
y
99-NotAnswer
ed
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Deat
hFor
m(
DTH)
WebVer
si
on:1.
0;4.
16;052016
1.Rec
or
ddat
eofdeat
h:
(
DTHDT)
2.Wasanaut
opsyper
f
or
med?(
AUTPERF)
(
mm/
dd/
yyy
y)
1-Yes
2-No
I
fyes,at
t
ac
hdei
dent
i
f
i
edaut
opsyr
epor
tordeat
hsummar
yt
ot
hef
or
m bel
ow.
Ent
erappr
opr
i
at
ecauseofdeat
hcodebel
ow.Li
sti
nor
derofdecr
easi
ngsever
i
t
y.
3.Pr
i
mar
ycauseofdeat
h:
(
CZDTHPRM)
?
Speci
f
yot
her
:
(
DTHSPEC1)
4.Secondar
ycauseofdeat
h:
(
SCNDCZ1)
Speci
f
yot
her
:
(
DTHSPEC2)
5.Secondar
ycauseofdeat
h:
(
SCNDCZ2)
Speci
f
yot
her
:
(
DTHSPEC3)
6.Secondar
ycauseofdeat
h:
(
SCNDCZ3)
Speci
f
yot
her
:
(
DTHSPEC4)
7.Secondar
ycauseofdeat
h:
(
SCNDCZ4)
Speci
f
yot
her
:
(
DTHSPEC5)
Comment
s:
(
DTCMMNTS)
Addi
t
i
ona
lSel
ect
i
onOpt
i
onsf
orDTH
Pr
i
mar
ycauseofdeat
h:
2.
2-Fungal
2.
3-Vi
r
al
2.
4-Pr
ot
oz
oal
2.
5-Ot
her
,Speci
f
yBel
ow
2.
9-Or
gani
s
m NotI
dent
i
f
i
ed
I
nt
er
st
i
t
i
al
Pneumoni
a
3.
1-Vi
r
al
,CMV
3.
2-Vi
r
al
,Ot
her
3.
3-Pneumocy
st
i
s
3.
4-Ot
her
,Speci
f
yBel
ow
3.
9-I
di
opat
hi
c
4.
0-Adul
tRespi
r
at
or
yDi
st
r
essSyndr
ome
5.
0-Acut
eGVHD
6.
0-Chr
oni
cGVHD
7.
0-Rec
ur
r
enceorPer
si
st
enc
eofLeukemi
a/
Mal
i
gnancy/
MDS
7.
1-Per
si
st
entDi
s
ease
Or
ganFai
l
ur
e(
NotDuet
oGVHD orI
nf
ect
i
on)
8.
1-Li
ver
8.
2-Car
di
ac(
Car
di
omy
opat
hy
)
8.
3-Pul
monar
y
8.
4-CNS
8.
5-Renal
8.
6-Ot
her
,Speci
f
yBel
ow
8.
7-Mul
t
i
pl
eOr
ganFai
l
ur
e,Spec
i
f
yBel
ow
8.
8-Secondar
yGr
af
tFai
l
ur
e
9.
0-Secondar
yMal
i
gnancy
9.
1-EBV
9.
2-Ot
her
,Speci
f
yBel
ow
Hemor
r
hage
10.
1-Pul
monar
y
10.
2-I
nt
r
acr
ani
al
10.
3-Gast
r
oi
nt
est
i
nal
10.
4-Hemor
r
hageNotSpeci
f
i
ed
10.
5-Ot
her
,Speci
f
yBel
ow
Vascul
ar
11.
1-Thr
omboembol
i
c
11.
2-Di
s
semi
nat
edI
nt
r
avas
cul
arCoagul
at
i
on(
DI
C)
11.
3-Gast
r
oi
nt
est
i
nal
11.
4-Thr
ombot
i
cThr
omboc
yt
openi
cPur
pur
a
11.
5-Vas
cul
arNotSpeci
f
i
ed
11.
9-Ot
her
,Speci
f
yBel
ow
12.
0-Ac
ci
dent
alDeat
h
13.
0-Ot
her
,Speci
f
yBel
ow
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Ex
t
r
acor
por
e
alPhot
opher
esi
s(
ECP)
WebVer
si
on:1.
0;2.
00;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
1.Assess
mentper
i
ods
t
ar
tdat
e:
(
ECPSTDT)
(
mm/
dd/
yyy
y)
2.Assess
mentper
i
odenddat
e:
(
ECPENDDT)
(
mm/
dd/
yyy
y)
ECPAdmi
ni
st
r
at
i
on:
Pr
ovi
dedat
esofECPt
r
eat
ment
sadmi
ni
s
t
er
eddur
i
ngt
hi
sassess
mentper
i
od.
ECPTr
eat
ment
s
Tr
eat
ment1:
ECPTr
eat
mentDat
e:
(
ECPDS01)
ECPDevi
ceUsed
(
mm/
dd/
yyy
y)
(
ECPDVC1)
Tr
eat
ment2:
(
ECPDS02)
(
mm/
dd/
yyy
y)
(
ECPDVC2)
Tr
eat
ment3:
(
ECPDS03)
(
mm/
dd/
yyy
y)
(
ECPDVC3)
Tr
eat
ment4:
(
ECPDS04)
(
mm/
dd/
yyy
y)
(
ECPDVC4)
Tr
eat
ment5:
(
ECPDS05)
(
mm/
dd/
yyy
y)
(
ECPDVC5)
Tr
eat
ment6:
(
ECPDS06)
(
mm/
dd/
yyy
y)
(
ECPDVC6)
Tr
eat
ment7:
(
ECPDS07)
(
mm/
dd/
yyy
y)
(
ECPDVC7)
Tr
eat
ment8:
(
ECPDS08)
(
mm/
dd/
yyy
y)
(
ECPDVC8)
Tr
eat
ment9:
(
ECPDS09)
(
mm/
dd/
yyy
y)
(
ECPDVC9)
Tr
eat
ment10:
(
ECPDS10)
(
mm/
dd/
yyy
y)
(
ECPDVC10)
Tr
eat
ment11:
(
ECPDS11)
(
mm/
dd/
yyy
y)
(
ECPDVC11)
Tr
eat
ment12:
(
ECPDS12)
(
mm/
dd/
yyy
y)
(
ECPDVC12)
Tr
eat
ment13:
(
ECPDS13)
(
mm/
dd/
yyy
y)
(
ECPDVC13)
Tr
eat
ment14:
(
ECPDS14)
(
mm/
dd/
yyy
y)
(
ECPDVC14)
Tr
eat
ment15:
(
ECPDS15)
(
mm/
dd/
yyy
y)
(
ECPDVC15)
Tr
eat
ment16:
(
ECPDS16)
(
mm/
dd/
yyy
y)
(
ECPDVC16)
Tr
eat
ment17:
(
ECPDS17)
(
mm/
dd/
yyy
y)
(
ECPDVC17)
Tr
eat
ment18:
(
ECPDS18)
(
mm/
dd/
yyy
y)
(
ECPDVC18)
Tr
eat
ment19:
(
ECPDS19)
(
mm/
dd/
yyy
y)
(
ECPDVC19)
Tr
eat
ment20:
(
ECPDS20)
(
mm/
dd/
yyy
y)
(
ECPDVC20)
3.HasECPbeenper
manent
l
ydi
sc
ont
i
nued?(
ECPDSCTD)
4.Dat
eofECPdi
s
cont
i
nuat
i
on:
(
ECPDSCDT)
5.Speci
f
yr
easonf
orper
manentdi
sc
ont
i
nuat
i
onofECP:
(
ECPDSRSN)
6.I
fOt
her
,spec
i
f
y:
(
ECPPDCRO)
Comment
s:
(
ECPCMMTS)
1-Yes
2-No
(
mm/
dd/
yyy
y)
Addi
t
i
ona
lSel
ect
i
onOpt
i
onsf
orECP
Speci
f
yr
easonf
orper
manentdi
scont
i
nuat
i
onofECP:
6-Hemodynami
ci
ns
t
abi
l
i
t
y
7-Pat
i
entr
ef
us
ed
9-Ot
her
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
0
801A(
ENR)
WebVer
si
on:1.
0;3.
03;101615
1.Rec
or
ddat
epat
i
enti
nf
or
medc
ons
entf
or
m si
gned:
(
CNSTDT)
(
mm/
dd/
y
yyy)
2.Pat
i
ent
'
sdat
eofbi
r
t
h:
(
BTHDT)
(
mm/
dd/
y
yyy)
3.Pat
i
ent
'
sbodywei
ght
:
(
PTWGHT)
(
xxx
.
x
) kg
4.Rec
or
ddat
epat
i
ent
'
sbodywei
ghtobt
ai
ned:
(
PTWGHDT)
(
mm/
dd/
y
yyy)
5.Pat
i
ent
'
shei
ght
:
(
PTHGHT)
(
x
xx) c
m
6.Rec
or
ddat
epat
i
ent
'
shei
ghtobt
ai
ned:
(
PTHGHTDT)
(
mm/
dd/
y
yyy)
7.Pat
i
entRi
sk(
see3.
1ofpr
ot
oc
ol
)
:
(
PTRI
SK)
1-Hi
ghr
i
sk
8.Att
het
i
meofdi
agnos
i
s,wast
hepat
i
entr
ecei
vi
ngst
er
oi
ds?(
PTSTRDS)
1-Yes
2-St
andar
dr
i
sk
2-No
I
fy
es
,spec
i
f
ys
t
er
oi
dr
ecei
ved:
9.Met
hy
l
pr
edni
s
ol
one:
(
MTPREDDX)
1-Yes
10.Recor
dt
hedos
eofmet
hyl
pr
edni
s
ol
oneatt
het
i
meofdi
agnosi
s:
(
MTPDSDX)
11.Pr
edni
sone:
(
PREDDX)
2-No
(
xx
x.
xx) mg/
kg/
day
1-Yes
12.Recor
dt
hedos
eofpr
edni
s
oneatt
het
i
meofdi
agnosi
s
:
(
PREDDSDX)
2-No
(
xx
x.
xx) mg/
kg/
day
I
ncl
us
i
onCr
i
t
er
i
a
13.Doest
hepat
i
enthavechr
oni
cGVHDorov
er
l
aps
yndr
omet
hatmeet
st
heNI
H
ConsensusWor
ki
ngGr
oupGui
del
i
nes?(
CGVHDNI
H)
1-Yes
14.Rec
or
dt
hedat
eofchr
oni
cGVHDdi
agnos
i
s:
(
CGVHDDT)
2-No
(
mm/
dd/
y
yyy)
15.Hast
hepat
i
entr
ec
ei
v
edanyoft
hef
ol
l
owi
ngagent
si
nt
hel
as
t2week
s?
(
THRPYGVH)
1-Yes
2-No
I
ft
hepat
i
enthasr
ecei
vedanyoft
hef
ol
l
owi
ngagent
s,i
ndi
cat
ewhi
chagent
swer
er
ecei
ved,t
her
easont
heagent
swer
er
ec
ei
vedandt
hes
t
ar
tdat
est
heagent
swer
e
r
ecei
v
ed:
AgentRecei
ved
16. Pr
edni
sone:
(
PREDNI
SO)
17.
Met
hyl
pr
edni
sol
one:
(
METPRED)
18. Si
r
ol
i
mus:
(
SI
ROLI
M)
1-Yes
1-Yes
1-Yes
ReasonAgentGi
ven
2-No
(
PREDREAS)
2-No
(
MPREREAS)
St
ar
tDat
e
(
PREDSTRT)
(
mm/
dd
(
MPREDSTR)
(
mm/
dd
/
yyy
y)
/
yyy
y)
(
SI
RLSTRT)
2-No
(
mm/
dd/
y
yyy)
(
SI
ROREAS)
19. Tac
r
ol
i
mus:
(
TACROLI
M)
1-Yes
(
TACSTART)
2-No
/
yyy
y)
(
mm/
dd
(
TACREAS)
20. Cyc
l
os
por
i
ne:
(
CYCLOSPO)
1-Yes
(
CYCLODT)
2-No
(
CYCLREAS)
(
mm/
dd/
yyy
y)
21. Ot
her
:
(
OTHERTRT)
1-Yes
(
OTRREASO)
2-No
(
OTRSTDT)
22.I
ft
hepat
i
entr
ecei
ved"
ot
her
"agent
,spec
i
f
yt
heagent
:
(
SPOTHRTR)
23.Recor
dt
hemostr
ecentdos
eofpr
edni
s
one:
(
PREDDOSE)
(
x.
x
x) mg/
kg/
day
24.Recor
dt
hemostr
ecentdos
eofmet
hyl
pr
edni
sol
one:
(
METPREDS)
(
x.
x
x) mg/
kg/
day
25.Hast
hepat
i
entbeent
r
eat
edwi
t
hex
t
r
acor
por
ealphot
opher
esi
s(
ECP)
?
(
EXCORPPH)
1-Yes
26.Recor
dt
hef
i
r
stdat
eofECPt
r
eat
ment
:
(
ECPFSTDT)
(
mm/
dd/
y
yyy)
27.Recor
dt
hel
as
tdat
eofECPt
r
eat
ment
:
(
ECPLSTDT)
(
mm/
dd/
y
yyy)
28.Recor
dt
het
ot
alnumberoft
r
eat
ment
sofECPr
ecei
ved:
(
NUMECPTR)
29.Hast
hepat
i
entbeeni
nadequat
el
yr
espondi
ngaf
t
erupt
o16weeksofchr
oni
c
GVHDt
her
apy?(
I
NADEQUA)
(
xx
)
1-Yes
MostRecentVal
ue
30. Cr
eat
i
ni
ne:
(
CREATN)
31. Cr
eat
i
ni
neCl
ear
ance:
(
CRTCLEAR)
2-No
(
x.
x
) mg/
dL
32. Absol
ut
eNeut
r
ophi
lCount(
ANC)
: (
CGVHANC)
2-No
Dat
eSampl
eObt
ai
ned
(
CRTDT)
(
mm/
dd/
yy
yy)
(
xxx
) mL/
mi
n
(
xxx
xx) /
μL (
ANCGVHDT)
33.I
st
hepat
i
entwi
l
l
i
ngt
ocompl
ywi
t
hst
udypr
oc
edur
esandr
epor
t
i
ngr
equi
r
ement
s?
(
WI
LCMPLY)
(
mm/
dd/
yy
yy)
1-Yes
2-No
34.I
st
hepat
i
entabl
et
obegi
npr
edni
s
onet
her
apyatadoseof≥0.
5mg/
kg/
day?
(
BEGNPRED)
1-Yes
2-No
35.Doest
hepat
i
enthaveani
nv
as
i
vef
ungalorvi
r
ali
nf
ect
i
onnotr
espondi
ngt
o
appr
opr
i
at
eant
i
f
ungalorant
i
vi
r
alt
her
api
es
?(
FUNGVI
R)
1-Yes
2-No
36.I
st
hepat
i
entunabl
et
ot
ol
er
at
eor
almedi
cat
i
ons?(
ORALMEDS)
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
3-NotAppl
i
c
abl
e
1-Yes
2-No
3-NotAppl
i
c
abl
e
1-Yes
2-No
3-NotAppl
i
c
abl
e
41.Hast
hepat
i
entr
ec
ei
v
edanyt
her
apyt
ot
r
eatper
si
st
ent
,pr
ogr
es
si
ve,orr
ecur
r
ent
mal
i
gnancy?(
THRPYMLG)
1-Yes
2-No
42.Doest
hepat
i
enthaveanypr
ogr
essi
v
eorr
ec
ur
r
entmal
i
gnanc
ydef
i
nedot
her
t
hanbyquant
i
t
at
i
vemol
ecul
aras
says
?(
MALI
GNAN)
1-Yes
2-No
43.Doest
hepat
i
enthaveaknownhyper
sens
i
t
i
vi
t
yt
osi
r
ol
i
mus?(
HYPERSI
R)
1-Yes
2-No
1-Yes
2-No
Excl
usi
onCr
i
t
e
r
i
a
37.Doest
hepat
i
entr
equi
r
epl
at
el
ett
r
ansf
us
i
ons?(
PLTTRANS)
38.I
st
hepat
i
entpr
egnant(
pos
i
t
i
veβHCG)orbr
east
f
eedi
ng?(
PTPREG)
39.I
st
hepat
i
entpr
egnant(
pos
i
t
i
veβHCG)orbr
east
f
eedi
ng?(
PTPREG)
40.I
ft
hepat
i
enti
saf
emal
eofchi
l
dbear
i
ngpot
ent
i
al
,i
st
hepat
i
entwi
l
l
i
ngt
ouse
c
ont
r
ac
ept
i
on?(
CONTRACE)
Conse
ntf
orBi
ol
ogi
calSampl
es
44.Hast
hepat
i
entconsent
edt
of
ut
ur
er
es
ear
c
hsampl
es?(
RSRCHSMP)
Comment
s:
(
COMMENTS)
(
mm/
dd/
y
yyy
)
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Fol
l
ow UpSt
at
usFor
m -0801(
FU6)
WebVer
si
on:1.
0;5.
00;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
1.Dat
eofl
astc
ont
ac
t
:
(
FU6LASTC)
(
mm/
dd/
yyy
y)
Si
ncet
hedat
eoft
hel
astvi
si
ti
ndi
cat
ei
fanyoft
hef
ol
l
owi
nghaveoccur
r
ed:
2.Hast
hepat
i
entdi
ed?(
FU6DI
ED)
1-Yes
2-No
I
fYes
,aDeat
hFor
m mus
tbes
ubmi
t
t
ed.
3.Dat
eofpat
i
entdeat
h:
(
FU6DTHDT)
4.Hast
hepat
i
ent
'
sunder
l
y
i
ngdi
s
ease(
e.
g.
,mal
i
gnanc
y)pr
ogr
ess
edorr
el
apsed?
(
FU6RLPS)
(
mm/
dd/
yyy
y)
1-Yes
5.Dat
eofr
el
apseordi
seasepr
ogr
ess
i
on:
(
FU6RLPDT)
6.Hast
hepat
i
ent
'
sunder
l
y
i
ngdi
s
ease(
e.
g.
,mal
i
gnanc
y)beent
r
eat
edf
or
pr
ogr
ess
i
onorr
el
apse?(
FU6RLPTR)
(
mm/
dd/
yyy
y)
1-Yes
7.Dat
et
r
eat
mentadmi
ni
st
er
ed:
(
FU6RLTDT)
8.Hast
hepat
i
entex
per
i
enc
edanyUnexpect
ed,Gr
ade35Adv
er
s
eEvent
?
(
FU6AEOCC)
2-No
2-No
(
mm/
dd/
yyy
y)
1-Yes
2-No
I
fYes
,anUnexpect
ed,Gr
ade35Adver
seEventmustbesubmi
t
t
ed.
9.Dat
eofonsetofUnex
pect
ed,Gr
ade35Adver
seEv
ent
:
(
FU6AEDT)
10.Hast
hepat
i
entex
per
i
enc
edanynewcl
i
ni
cal
l
ysi
gni
f
i
canti
nf
ect
i
ons
?(
FU6SI
GI
N)
(
mm/
dd/
yyy
y)
1-Yes
2-No
I
fYes
,anI
nf
ect
i
onFor
m mus
tbes
ubmi
t
t
ed.
11.Dat
eofi
nf
ec
t
i
on:
(
FU6I
NFDT)
12.Hast
hepat
i
entbeenhospi
t
al
i
z
ed?(
FU6HOSPI
)
(
mm/
dd/
yyy
y)
1-Yes
2-No
I
fYes
,aReAdmi
ssi
onFor
m mustbesubmi
t
t
ed.
13.Dat
eofhospi
t
al
i
z
at
i
on:
(
FU6HOSDT)
14.Hast
hepat
i
entr
ec
ei
v
edaDLI
?(
FU6DLI
)
15.Dat
eofDLI
:
(
FU6DLI
DT)
16.Hast
hepat
i
entr
ec
ei
v
edasecondt
r
anspl
ant
?(
FU6SCTRA)
17.Speci
f
ysecondt
r
anspl
ant
:
(
FU6SCTRS)
(
mm/
dd/
yyy
y)
1-Yes
(
mm/
dd/
yyy
y)
1-Yes
18.Dat
eofs
ec
ondt
r
ans
pl
ant
:
(
FU6STRDT)
19.Hast
hepat
i
entst
ar
t
edanysecondar
ysys
t
emi
ci
mmunosuppr
es
si
vet
her
apyt
o
t
r
eatchr
oni
cGVHD?(
FU6SCTPY)
2-No
2-No
(
mm/
dd/
yyy
y)
1-Yes
2-No
I
fYes
,aSecondar
yTher
apyFor
m mustbesubmi
t
t
ed.Secondar
yi
mmunosuppr
es
si
v
e
s
yst
emi
ct
her
apyi
nc
l
udesanyi
nt
er
vent
i
oni
nt
endedt
ocont
r
olc
hr
oni
cGVHD t
hr
oughan
i
mmunosuppr
ess
i
veef
f
ectf
r
om or
alorpar
ent
er
aladmi
ni
st
r
at
i
onofanysy
st
emi
c
medi
cat
i
onnotor
i
gi
nal
l
ygi
v
enundert
heauspi
cesoft
hi
spr
ot
ocolf
ort
r
eat
mentof
c
hr
oni
cGVHD.Pl
easeseeSect
i
on3.
3.
2oft
hepr
ot
ocolf
orex
ampl
es.
20.Dat
epat
i
entbegans
econdar
ysys
t
emi
ci
mmunosuppr
ess
i
vet
her
apy:
(
FU6TRTDT)
21.I
st
hepat
i
entcur
r
ent
l
yon<5mg/
dayt
ot
aldoseofpr
edni
sone?(
FU6PRED)
22.Dat
epr
edni
sonedos
eof<5mg/
dayst
ar
t
ed:
(
FU6PRDDT)
23.Hast
hepat
i
entst
oppedal
l
SECONDARYs
yst
emi
ci
mmunos
uppr
essi
v
et
her
apy
?
(
FU6SYSTH)
(
mm/
dd/
yyy
y)
1-Yes
1-Yes
24.Dat
et
hepat
i
ents
t
oppedSECONDARYi
mmunosuppr
ess
i
vet
her
apy:
(
FU6OFFDT)
25.Hast
hepat
i
entst
oppedALLi
mmunosuppr
ess
i
vet
her
apy
,i
nc
l
udi
ngst
udyt
her
apy
?
(
FU6SALLT)
26.Dat
et
hepat
i
ents
t
oppedALLi
mmunos
uppr
essi
v
et
her
apy
,i
ncl
udi
ngst
udy
t
her
apy:
(
FU6SATDT)
2-No
3-Pr
evi
ous
l
yRepor
t
ed
(
mm/
dd/
yyy
y)
2-No
3-Nev
erSt
ar
t
ed
(
mm/
dd/
yyy
y)
1-Yes
2-No
3-Pr
evi
ous
l
yRepor
t
ed
(
mm/
dd/
yyy
y)
27.Reasonpat
i
entst
oppedi
mmunos
uppr
essi
v
et
her
apy,i
ncl
udi
ngst
udy
t
her
apy:
(
FU6SATRN)
28.I
fphys
i
ci
andec
i
si
onorot
her
,s
pec
i
f
y:
(
FU6SATRO)
Per
i
pher
albl
oodsampl
esf
orpl
as
maBAFFl
evel
sandr
egul
at
or
yTcel
landBcel
li
mmunophenot
y
pi
ngmustbecol
l
ect
edpr
i
ort
ot
hef
i
r
stt
i
mes
ec
ondar
ysyst
emi
c
i
mmunos
uppr
essi
vet
her
apyi
sadmi
ni
st
er
ed.
29.Wer
ebl
oodsampl
esf
orBAFFl
evel
sbyELI
SAcol
l
ect
ed?(
FU6BAFF)
1-Yes
30.Dat
et
hebl
oodsampl
eswer
ecol
l
ec
t
ed:
(
FU6BFFDT)
31.Wer
ebl
oodsampl
esf
orRegul
at
or
yTcel
landBcel
lI
mmunophenot
ypi
ng
c
ol
l
ect
ed?(
FU6TBCL)
32.Dat
et
hebl
oodsampl
eswer
ecol
l
ec
t
ed.
(
FU6TBDT)
Comment
s:
(
FU6COMM)
2-No
(
mm/
dd/
yyy
y)
1-Yes
2-No
(
mm/
dd/
yyy
y)
Addi
t
i
ona
lSel
ect
i
onOpt
i
onsf
orFU6
Reasonpat
i
entst
oppedi
mmunosuppr
essi
vet
her
apy,i
ncl
udi
ngst
udyt
her
apy:
6-Ot
her
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on1-Pat
i
entcGVHD Sur
v
ey(
GC1)
WebVer
si
on:1.
0;3.
01;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on1:YourChr
oni
cGr
af
tv
s.HostDi
sea
se(
GVHD)Sympt
oms
Dat
eofas
sessment
:
(
GC1ASDT)
(
mm/
dd/
y
yyy
)
Pl
eases
el
ectt
henumbert
hatshowshowsever
eyoursy
mpt
omshav
ebeeni
nt
hel
astweek
wi
t
h0r
epr
esent
i
ng'
NotPr
esent
'
and10r
epr
esent
i
ng'
AsBadAsYouCanI
magi
ne'
:
0
1
2
3
4
5
6
7
8
9
10
NotAnswer
ed
1. Yourchr
oni
cGVHDsympt
omsover
al
l
? (
GC1CGVHD)
2. Yourski
ni
t
chi
ngati
t
sWORST?
(
GC1SKI
N)
3. Yourmout
hdr
ynessati
t
sWORST?
4. Yourmout
hpai
nati
t
sWORST?
(
GC1MTDRY)
(
GC1MTPN)
5. Yourmout
hsensi
t
i
vi
t
yati
t
sWORST? (
GC1MTSEN)
6. Youreyepr
obl
em ati
t
sWORST?
(
GC1EYE)
7.Whati
sy
ourmai
ncompl
ai
ntwi
t
hr
egar
dt
oyoureyes?(
GC1EYECO)
8.Vul
vovagi
nalSympt
oms(
f
emal
esonl
y)
:Doy
ouhaveanybur
ni
ng,pai
nor
di
sc
omf
or
ti
nt
hear
eaofyourvagi
na,vul
vaorl
abi
a?OR-Doy
ouhav
eany
di
sc
omf
or
torpai
nwi
t
hs
exuali
nt
er
cour
se?(
GC1DCDSX)
1-Yes
2-No
3-N/
A
4-NotAns
wer
ed
1-Yes
2-No
3-N/
A
4-NotAns
wer
ed
9.Over
al
l
,howwoul
dy
our
at
et
hes
ever
i
t
yofyourc
hr
oni
cgr
af
tvshostdi
seas
e?
(
GC1SGVHD)
10.Doyout
hi
nkyourchr
oni
cGVHDsympt
omsar
ei
ngoodenoughcont
r
olt
o
decr
easeyouri
mmunosuppr
es
si
vemedi
cat
i
ons?(
GC1DMED)
0-Noti
nvol
ved
wi
t
hGVHD
11. GVHD
Sy
mpt
oms
Ov
er
al
l
:
-
12. Mout
h:
(
GC1MOUTH)
13. Ski
n:
(
GC1SKN)
14. Eye:
(
GC1EYESX)
15. Joi
nt
s:
(
GC1JNTS)
Comment
s:
(
GC1COMM)
1-Compl
et
el
y
gone
(
GC1OGVHD)
2-Ver
y
much
bet
t
er
3Moder
at
el
y
bet
t
er
4-A
l
i
t
t
l
e
bet
t
er
5-About
t
he
same
6-A
l
i
t
t
l
e
wor
se
7Moder
at
el
y
wose
8-Ver
y
much
wor
se
Not
Answer
ed
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on2-Pat
i
entcGVHD Sur
v
ey(
GC2)
WebVer
si
on:1.
0;1.
02;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on2:Det
ai
l
sofYourChr
oni
cGVHDSympt
oms
Pl
eas
esel
ectt
henumbert
hati
ndi
c
at
eshow muc
hyouhavebeenbot
her
edbyt
hef
ol
l
owi
ngpr
obl
emsi
nt
hel
ast4weeks
:
SKI
N:
0-Notatal
l
1-Sl
i
ght
l
y 2-Moder
at
el
y 3-Qui
t
eABi
t 4-Ext
r
emel
y NotAnswer
ed
1. Abnor
mal
ski
nc
ol
or (
GC2ABNSK)
2. Ras
hes
(
GC2RASH)
3. Thi
ckenedsk
i
n
(
GC2THSKN)
4. Sor
esons
ki
n
(
GC2SKSOR)
5. I
t
chys
ki
n
(
GC2I
TCSK)
EYESAND MOUTH:
0-NotAtAl
l
6. Dr
yeyes
(
GC2EYEDR)
7. Needt
ouseeyedr
opsf
r
equent
l
y
(
GC2EDFRQ)
8. Di
f
f
i
cul
t
ys
eei
ngcl
ear
l
y
1Sl
i
ght
l
y
2Moder
at
el
y
3-Qui
t
eA
Bi
t
4Ext
r
emel
y
(
GC2DI
FSE)
9. Needt
oavoi
dcer
t
ai
nf
oodsduet
omout
hpai
n
10. Ul
c
er
si
nmout
h
(
GC2AFOOD)
(
GC2ULCER)
11. Recei
vi
ngnut
r
i
t
i
onf
r
omani
nt
r
av
enousl
i
neorf
eedi
ng
t
ube
(
GC2NUTR)
BREATHI
NG:
0-NotAtAl
l
12. Fr
equentcough
(
GC2FRQCH)
13. Col
or
edsput
um
(
GC2COLOR)
1-Sl
i
ght
l
y 2-Moder
at
el
y 3-Qui
t
eA Bi
t 4-Ext
r
emel
y NotAnswer
ed
14. Shor
t
nes
sofbr
eat
hwi
t
hex
er
ci
se (
GC2SOBEX)
15. Shor
t
nes
sofbr
eat
hatr
est
(
GC2SOBRT)
16. Needt
ous
eox
ygen
(
GC2NDOX)
EATI
NG ANDDI
GESTI
ON:
0-NotAtAl
l
17. Di
f
f
i
cul
t
yswal
l
owi
ngsol
i
df
oods (
GC2DSSF)
18. Di
f
f
i
cul
t
yswal
l
owi
ngl
i
qui
ds
(
GC2DSLD)
1-Sl
i
ght
l
y 2-Moder
at
el
y 3-Qui
t
eABi
t 4-Ext
r
emel
y NotAnswer
ed
Not
Answer
ed
19. Vomi
t
i
ng
(
GC2VOMI
T)
20. Wei
ghtl
oss
(
GC2WTLS)
MUSCLESANDJOI
NTS:
0-NotAtAl
l
21. Joi
ntandmusc
l
eac
hes
(
GC2J
I
ONT)
22. Li
mi
t
edj
oi
ntmovement
(
GC2LTJTM)
23. Musc
l
ecr
amps
(
GC2MUSCR)
24. WeakMuscl
es
(
GC2WKMUS)
1-Sl
i
ght
l
y 2-Moder
at
el
y 3-Qui
t
eABi
t 4-Ext
r
emel
y NotAnswer
ed
ENERGY:
0-NotAtAl
l
25. Lossofener
gy
1-Sl
i
ght
l
y 2-Moder
at
el
y 3-Qui
t
eA Bi
t 4-Ext
r
emel
y NotAnswer
ed
(
GC2LSERG)
26. Needt
osl
eepmor
e/
t
ak
enaps (
GC2SLEEP)
27. Fever
s
(
GC2FEVER)
MENTALANDEMOTI
ONAL:
0-NotAtAl
l
28. Depr
essi
on
29. Anx
i
et
y
(
GC2DEPRS)
(
GC2ANXY)
30. Di
f
f
i
cul
t
ysl
eepi
ng (
GC2DFSLP)
Comment
s:
(
GC2COMM)
1-Sl
i
ght
l
y 2-Moder
at
el
y 3-Qui
t
eA Bi
t 4-Ext
r
emel
y NotAnswer
ed
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on3-Pat
i
entcGVHD Sur
v
ey(
GC3)
WebVer
si
on:1.
0;1.
01;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on3:Det
ai
l
sofYourEy
eSympt
oms
Havey
ouexper
i
enc
edanyoft
hef
ol
l
owi
ngi
nt
hel
ast
week?
1-Noneoft
he
t
i
me
1. Eyest
hatar
es
ens
i
t
i
vet
ol
i
ght
?
(
GC3ELSEN)
2. Eyest
hatf
eelgr
i
t
t
y
?
(
GC3EGRI
T)
3. Pai
nf
ulorsor
eeyes?
(
GC3EPAI
N)
4. Bl
ur
r
edv
i
si
on?
(
GC3EBLUR)
5. Poorvi
si
on?
(
GC3EPOOR)
Havepr
obl
emswi
t
hyoureyesl
i
mi
t
edyoui
nper
f
or
mi
ngany
oft
hef
ol
l
owi
ngdur
i
ngt
hel
astweek?
1-Noneoft
he
t
i
me
6. Readi
ng?
(
GC3EREAD)
7. Dr
i
v
i
ngatni
ght
?
3-Hal
fof
t
het
i
me
4-Mostof
t
het
i
me
5-Al
lof
t
het
i
me
Not
Answer
ed
2-Someof
t
het
i
me
3-Hal
fof
t
het
i
me
4-Mostof
t
het
i
me
5-Al
lof
t
het
i
me
Not
Answer
ed
0N/
A
2-Someof
t
het
i
me
3-Hal
fof
t
het
i
me
4-Mostof
t
het
i
me
5-Al
lof
t
het
i
me
Not
Answer
ed
0N/
A
(
GC3EDRI
V)
8. Wor
ki
ngwi
t
hac
omput
erorbankmachi
ne(
ATM)
?
(
GC3ECOMP)
9. Wat
chi
ngTV?
(
GC3ETV)
Havey
ourey
esf
el
tuncomf
or
t
abl
ei
nanyoft
hef
ol
l
owi
ng
si
t
uat
i
onsdur
i
ngt
hel
astweek?
1-Noneoft
he
t
i
me
10. Wi
ndyc
ondi
t
i
ons?
(
GC3EWI
ND)
11. Pl
acesorar
easwi
t
hl
ow humi
di
t
y(
v
er
ydr
y)
?
(
GC3EHUMD)
12. Ar
east
hatar
eai
rcondi
t
i
oned?
(
GC3EAI
R)
Comment
s:
(
GC3COMM)
2-Someof
t
het
i
me
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on4-Pat
i
entcGVHD Sur
v
ey(
GC4)
WebVer
si
on:1.
0;1.
02;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on4:Qual
i
t
yofYourLi
f
e
Pl
eas
esel
ectt
henumbert
hati
ndi
c
at
eshow eachst
at
ementhasbeent
r
uef
ory
oudur
i
ngt
hepastweek:
PHYSI
CALWELLBEI
NG:
0-NotAtAl
l
1. I
hav
el
ac
kofener
gy
(
GC4LKENG)
2. I
hav
enausea
(
GC4NAUSE)
3. Becauseofmyphysi
c
al
condi
t
i
on,Ihavet
r
oubl
emeet
i
ngt
he
needsofmyf
ami
l
y
(
GC4FMND)
4. I
hav
epai
n
(
GC4PAI
N)
5. I
ambot
her
edbys
i
deef
f
ect
soft
r
eat
ment
(
GC4SETRT)
6. I
f
eeli
l
l
(
GC4I
LL)
7. I
amf
or
cedt
os
pendt
i
mei
nbed
(
GC4FCBED)
1-ALi
t
t
l
e
Bi
t
2Somewhat
3-Qui
t
eA
Bi
t
4-Ver
y
Much
Not
Answer
ed
SOCI
AL/
FAMI
LY WELLBEI
NG:
0-NotAtAl
l
8. I
f
eelcl
oset
omyf
r
i
ends
(
GC4FRDS)
9. I
getemot
i
onals
uppor
tf
r
ommyf
ami
l
y
(
GC4FAMSP)
10. Igetsuppor
tf
r
om myf
r
i
ends
(
GC4FRDSP)
11. Myf
ami
l
yhasaccept
edmyi
l
l
ness
(
GC4FAMAC)
12. Iam s
at
i
sf
i
edwi
t
hf
ami
l
yc
ommuni
cat
i
onaboutmyi
l
l
ness
(
GC4FAMCO)
13. If
eel
cl
oset
omypar
t
ner(
ort
heper
sonwhoi
smymai
nsuppor
t
)
(
GC4CLPRT)
Regar
dl
essofyourcur
r
entl
evelofsexualact
i
vi
t
y,pl
easeanswert
hef
ol
l
owi
ng
quest
i
on.Doyouwi
sht
oanswert
hi
squest
i
on?I
fno,t
hencont
i
nuet
ot
henext
sect
i
on(
Q15)
.
(
GC4PRANS)
14. Iam s
at
i
sf
i
edwi
t
hmys
exl
i
f
e
(
GC4VULVA)
1-A
Li
t
t
l
e
Bi
t
23Somewhat Qui
t
eA
Bi
t
4-Ver
y
Much
Not
Answer
ed
EMOTI
ONALWELLBEI
NG:
0-NotAtAl
l
15. If
eel
sad
1-ALi
t
t
l
eBi
t 2-Somewhat 3-Qui
t
eABi
t 4-Ver
yMuch NotAnswer
ed
(
GC4SAD)
16. Iam s
at
i
sf
i
edwi
t
hhow I
am c
opi
ngwi
t
hmyi
l
l
ness
(
GC4COPE)
17. Iam l
osi
nghopei
nt
hef
i
ghtagai
nstmyi
l
l
ness
(
GC4LHOPE)
18. If
eel
ner
vous
(
GC4NERVE)
19. Iwor
r
yaboutdyi
ng
(
GC4WYDI
E)
20. Iwor
r
yt
hatmycondi
t
i
onwi
l
lgetwor
se
(
GC4CNTWS)
FUNCTI
ONALWELLBEI
NG:
0-NotAtAl
l
21. Iam abl
et
owor
k(
i
ncl
udewor
kathome)
(
GC4WORK)
22. Mywor
k(
i
ncl
udewor
kathome)i
sf
ul
f
i
l
l
i
ng
(
GC4WKFUL)
23. Iam abl
et
oenj
oyl
i
f
e
(
GC4ENJOY)
24. Ihaveac
cept
edmyi
l
l
ness
(
GC4ACPTI
)
25. Iam s
l
eepi
ngwel
l
26. Iam enj
oyi
ngt
het
hi
ngsIusual
l
ydof
orf
un
1-A Li
t
t
l
eBi
t 2-Somewhat 3-Qui
t
eABi
t 4-Ver
yMuch NotAnswer
ed
(
GC4SLPWL)
(
GC4FFUN)
27. Iam c
ont
entwi
t
ht
hequal
i
t
yofmyl
i
f
er
i
ghtnow (
GC4CNTWL)
ADDI
TI
ONALCONCERNS:
0-NotAtAl
l
28. Iam c
onc
er
nedaboutkeepi
ngmyj
ob(
i
nc
l
udewor
kat
home)
(
GC4CNJOB)
29. If
eel
di
s
t
antf
r
om ot
herpeopl
e
(
GC4DI
STN)
30. Iwor
r
yt
hatt
het
r
anspl
antwi
l
l
notwor
k
(
GC4WYTRS)
31. Theef
f
ec
t
soft
r
eat
mentar
ewor
s
et
hanwhatIhad
i
magi
ned
(
GC4TRTWS)
32. Ihaveagoodappet
i
t
e
(
GC4GAPPT)
33. Il
i
k
et
heappear
anceofmybody
(
GC4APBOD)
34. Iam abl
et
ogetar
oundbymy
sel
f
(
GC4GETAR)
35. Igett
i
r
edeasi
l
y
(
GC4TI
RED)
36. Iam i
nt
er
est
edi
nsex
(
GC4I
TRSX)
37. Ihavec
onf
i
dencei
nmynur
se(
s)
Comment
s:
(
GC4COMM)
(
GC4CONRN)
1-ALi
t
t
l
e
Bi
t
2Somewhat
3-Qui
t
eA
Bi
t
4-Ver
y
Much
Not
Answer
ed
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on5-Pat
i
entcGVHD Sur
v
ey(
GC5)
WebVer
si
on:1.
0;1.
01;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on5:YourHeal
t
ha
ndWel
l
Be
i
ng
Pl
eases
el
ectt
henumbert
hatbes
tdesc
r
i
besyouranswer
:
1.Whi
chst
at
ementdesc
r
i
beshowyouf
eelmostoft
het
i
me?(
GC5FMTM)
2.I
ngener
al
,woul
dyousayyourheal
t
hi
s:
(
GC5GNHLT)
1-Ex
c
el
l
ent
NotAns
wer
ed
3.Compar
edt
o3mont
hsago,howwoul
dyour
at
ey
ourheal
t
hi
ngener
al
now(
GC5HLTMO)
1-Muchbet
t
er
Somewhatwor
se
2-Ver
yGood
3-Good
2-Somewhatbet
t
er
5-Muchwor
s
e
4-Fai
r
3-Aboutt
hes
ame
6-NotAnswer
ed
5-Poor
6-
4-
Thef
ol
l
owi
ngques
t
i
onsar
eaboutact
i
v
i
t
i
esy
oumi
ghtdodur
i
ngat
ypi
calday.Doesy
ourheal
t
hnowl
i
mi
tyoui
nt
hes
eact
i
vi
t
i
es
?I
fso,howmuc
h?
1-Yes,l
i
mi
t
eda
l
ot
4. Vi
gor
ousact
i
v
i
t
i
es,suchasr
unni
ng,l
i
f
t
i
ngheav
yobj
ect
s
,par
t
i
c
i
pat
i
ngi
n
st
r
enuousspor
t
s
(
GC5VGACT)
5. Moder
at
eact
i
v
i
t
i
es,suchasmov
i
ngat
abl
e,pushi
ngavacuum cl
eaner
,
bowl
i
ng,orpl
ay
i
nggol
f
(
GC5MDACT)
6. Li
f
t
i
ngorcar
r
y
i
nggr
ocer
i
es
(
GC5LI
FTG)
7. Cl
i
mbi
ngsever
al
f
l
i
ght
sofs
t
ai
r
s
(
GC5CLI
MB)
8. Cl
i
mbi
ngonef
l
i
ghtofst
ai
r
s
(
GC5CLBFL)
9. Bendi
ng,kneel
i
ngorst
oopi
ng
(
GC5BEND)
10. Wal
ki
ngmor
et
hanami
l
e
(
GC5WALKM)
11. Wal
ki
ngsever
alhundr
edyar
ds
(
GC5WALKF)
12. Wal
ki
ngonehundr
edyar
ds
(
GC5WLKHY)
13. Bat
hi
ngordr
ess
i
ngyour
s
el
f
(
GC5BATH)
2-Yes,l
i
mi
t
eda
l
i
t
t
l
e
3-No,notl
i
mi
t
ed
atal
l
Not
Answer
ed
Dur
i
ngt
hepas
t4weeks,how muc
hoft
het
i
mehav
eyouhadanyoft
hef
ol
l
owi
ngpr
obl
emswi
t
hyourwor
korot
herr
egul
ardai
l
yact
i
vi
t
i
esasar
esul
tofyourphysi
cal
heal
t
h?
1-Al
loft
he
t
i
me
14. Cutdownont
heamountoft
i
meyouspentonwor
kor
ot
heract
i
vi
t
i
es
(
GC5CUTDN)
15. Acc
ompl
i
shedl
esst
hanyouwoul
dl
i
ke
(
GC5ACCPL)
16. Wer
el
i
mi
t
edi
nt
hek
i
ndofwor
korot
herac
t
i
vi
t
i
es
(
GC5LI
MI
T)
2-Mostof
t
het
i
me
3-Someof
t
het
i
me
4-A l
i
t
t
l
eof
t
het
i
me
5-Noneof
t
het
i
me
Not
Answer
ed
17. Haddi
f
f
i
cul
t
yper
f
or
mi
ngt
hewor
korot
heract
i
v
i
t
i
es
(
f
orex
ampl
e,i
tt
ookext
r
aef
f
or
t
)
(
GC5DI
FPE)
Dur
i
ngt
hepas
t4weeks,how muc
hoft
het
i
mehav
eyouhadanyoft
hef
ol
l
owi
ngpr
obl
emswi
t
hyourwor
korot
herr
egul
ardai
l
yact
i
vi
t
i
esasar
esul
tofyouremot
i
onal
pr
obl
ems(
s
uchasf
eel
i
ngdepr
es
sedoranxi
ous)
?
1-Al
loft
he
t
i
me
18. Cutdownont
heamountoft
i
meyouspenton
wor
korot
herac
t
i
vi
t
i
es
(
GC5DUTDN)
19. Acc
ompl
i
shedl
esst
hanyouwoul
dl
i
ke
(
GC5LACCP)
20. Di
dwor
konot
heract
i
v
i
t
i
esl
esscar
ef
ul
l
yt
han
usual
(
GC5LCARE)
2-Mostoft
he
t
i
me
3-Someoft
he 4-A l
i
t
t
l
eoft
he 5-Noneoft
he
t
i
me
t
i
me
t
i
me
21.Dur
i
ngt
hepast4weeks
,t
owhatext
enthasy
ourphys
i
calheal
t
horemot
i
onal
1-NotAtAl
l
2-Sl
i
ght
l
y
pr
obl
emsi
nt
er
f
er
edwi
t
hyournor
mal
soci
alact
i
v
i
t
i
eswi
t
hf
ami
l
y,f
r
i
ends,
Ex
t
r
emel
y
6-NotAnswer
ed
nei
ghbor
s,orgr
oups?(
GC5PHI
NT)
22.Howmuc
hbodi
l
ypai
nhaveyouhaddur
i
ngt
hepast4weeks
?(
GC5BPAI
N)
1-None
2-Ver
yMi
l
d
6-Ver
ySever
e
23.Dur
i
ngt
hepast4weeks
,howmuc
hdi
dpai
ni
nt
er
f
er
ewi
t
hyournor
mal
wor
k
(
i
ncl
udi
ngbot
hwor
kout
s
i
det
hehomeandhousewor
k)
?(
GC5PAI
NW)
3-Mi
l
d
7-NotAnswer
ed
1-NotAtAl
l
Ex
t
r
emel
y
3-Moder
at
el
y
2-Sl
i
ght
l
y
Not
Answer
ed
4-Qui
t
eABi
t
4-Moder
at
e
3-Moder
at
el
y
5-
5-Sever
e
4-Qui
t
eABi
t
5-
6-NotAnswer
ed
Thesequest
i
onsar
eabouthow y
ouf
eelandhow t
hi
ngshavebeenwi
t
hyoudur
i
ngt
hepas
t4week
s.Foreachquest
i
on,pl
easegi
vet
heoneanswert
hatcomescl
os
estt
o
t
hewayy
ouhav
ebeenf
eel
i
ng.Howmuchoft
het
i
medur
i
ngt
hepas
t4weeks.
1-Al
loft
het
i
me 2-Mostoft
he 3-Someoft
he
t
i
me
t
i
me
24. Di
dy
ouf
eel
f
ul
lofl
i
f
e?
(
GC5VNERV)
26. Havey
ouf
el
tsodowni
nt
hedumpst
hatnot
hi
ng
coul
dcheeryouup?
(
GC5CHEER)
Not
Answer
ed
(
GC5CALM)
28. Di
dy
ouhaveal
otofener
gy?
(
GC5LTENG)
29. Havey
ouf
el
tdownhear
t
edanddepr
essed?
(
GC5FTDOW)
30. Di
dy
ouf
eel
wor
nout
?
(
GC5WORNO)
31. Havey
oubeenhappy
?
(
GC5HAPPY)
32. Di
dy
ouf
eel
t
i
r
ed?
5-Noneoft
he
t
i
me
(
GC5FULLL)
25. Havey
oubeenv
er
yner
v
ous
?
27. Havey
ouf
el
tcal
m andpeacef
ul
?
4-Al
i
t
t
l
eof
t
het
i
me
(
GC5FTI
RE)
33.Dur
i
ngt
hepast4weeks
,howmuc
hoft
het
i
mehasy
ourphys
i
c
alheal
t
hof
emot
i
onal
pr
obl
emsi
nt
er
f
er
edwi
t
hy
oursoci
alact
i
v
i
t
i
es(
l
i
k
evi
si
t
i
ngf
r
i
ends,
r
el
at
i
ves,et
c
)
?(
GC5EMI
NT)
1-Al
loft
het
i
me
oft
het
i
me
2-Mostoft
het
i
me
5-Noneoft
het
i
me
3-Someoft
het
i
me
4-Al
i
t
t
l
e
6-NotAnswer
ed
HowTRUEorFALSEi
seac
hoft
hef
ol
l
owi
ngst
at
ement
sf
oryou?
1-Def
i
ni
t
el
yTr
ue
34. Is
eem t
ogetsi
c
kal
i
t
t
l
eeasi
ert
hanot
her
peopl
e
(
GC5MSI
CK)
35. Iam asheal
t
hyasanybodyI
know
(
GC5HLTAN)
36. Iex
pec
tmyheal
t
ht
ogetwor
se
(
GC5HTWOR)
2-Most
l
y
Tr
ue
3-Don'
t
Know
4-Most
l
y
Fal
se
5-Def
i
ni
t
el
y
Fal
se
Not
Answer
ed
37. Myheal
t
hi
sex
cel
l
ent
Comment
s:
(
GC5COMM)
(
GC5EXCEL)
Addi
t
i
ona
lSel
ect
i
onOpt
i
onsf
orGC5
Whi
chst
at
ementdescr
i
beshow youf
eelmostoft
het
i
me?
6-Requi
r
econsi
der
abl
eassi
s
t
anceandf
r
equentmedi
c
al
car
e
7-Di
s
abl
ed,r
equi
r
especi
alcar
eandassi
s
t
ance
8-Sever
el
ydi
sabl
ed,hospi
t
al
i
z
ed
9-Ver
ysi
ck
,hospi
t
al
i
z
ed
10-NotAnswer
ed
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on6-Pat
i
entcGVHD Sur
v
ey(
GC6)
WebVer
si
on:1.
0;1.
01;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on6:YourAct
i
vi
t
yLevel
1-St
i
l
lDoi
ngThi
s
Act
i
vi
t
y
1. Get
t
i
ngi
nandoutofc
hai
r
sorbed(
wi
t
houtass
i
s
t
ance)
(
GC6GETUP)
2. Li
st
eni
ngt
ot
her
adi
o
(
GC6RADI
O)
3. Readi
ngbooks
,magaz
i
nesornewspaper
s
(
GC6READ)
4. Wr
i
t
i
ng(
l
et
t
er
s,not
es
)
(
GC6WRI
TE)
5. Wor
ki
ngatadeskort
abl
e
(
GC6WDESK)
6. St
andi
ng(
f
ormor
et
hanonemi
nut
e)
(
GC6STAND)
7. St
andi
ng(
f
ormor
et
hanf
i
vemi
nut
es)
(
GC6STNDF)
8. Dr
es
si
ngorundr
essi
ng(
wi
t
houtassi
s
t
ance)
(
GC6DRSWO)
9. Get
t
i
ngc
l
ot
hesf
r
om dr
awer
sorc
l
oset
s
(
GC6CLOTH)
10. Get
t
i
ngi
noroutofacar(
wi
t
houtas
si
st
ance)
(
GC6OOCAR)
11. Di
ni
ngatar
es
t
aur
ant
(
GC6DI
NE)
12. Pl
ayi
ngcar
ds/
t
abl
egames
(
GC6PCARD)
13. Taki
ngabat
h(
noassi
s
t
anceneeded)
(
GC6BATHN)
14. Put
t
i
ngons
hoes,st
ocki
ngsors
ocks(
noassi
st
anc
e
needed)
(
GC6SHOES)
15. At
t
endi
ngamovi
e,pl
ay
,chur
c
heventors
por
t
s
act
i
v
i
t
y
(
GC6MOVI
E)
16. Wal
ki
ng30yar
ds(
27met
er
s)
(
GC6TYWLK)
17. Wal
ki
ng30yar
ds(
nonst
op)
(
GC6TYDWK)
18. Dr
ess
i
ng/
undr
essi
ng(
nor
estorbr
eakneeded)
(
GC6DRSNS)
19. Us
i
ngpubl
i
ct
r
ans
por
t
at
i
onordr
i
v
i
ngacar(
100mi
l
es
orl
ess)
(
GC6PUBTR)
20. Us
i
ngpubl
i
ct
r
ans
por
t
at
i
onordr
i
v
i
ngacar(
99mi
l
es
ormor
e)
(
GC6PTLD)
21. Cooki
ngyourownmeal
s
(
GC6COOK)
22. Washi
ngordr
yi
ngdi
shes
(
GC6WHDSH)
23. Put
t
i
nggr
ocer
i
esonshel
ves
(
GC6GROCS)
24. I
r
oni
ngorf
ol
di
ngc
l
ot
hes
(
GC6I
RON)
25. Dust
i
ng/
pol
i
shi
ngf
ur
ni
t
ur
eorpol
i
shi
ngcar
s
(
GC6DUST)
26. Shower
i
ng
(
GC6SHOWR)
2-HaveSt
oppedDoi
ngThi
s
Act
i
vi
t
y
3-NeverDi
dThi
s
Act
i
vi
t
y
Not
Answer
ed
27. Cl
i
mbi
ngsi
xst
eps
(
GC6CLBST)
28. Cl
i
mbi
ngsi
xst
eps(
nonst
op)
(
GC6CBSSN)
29. Cl
i
mbi
ngni
nes
t
eps
(
GC6CLBNS)
30. Cl
i
mbi
ng12st
eps
(
GC6CLBTS)
31. Wal
ki
ng1/
2bl
ockonl
evelgr
ound
(
GC6WKGDL)
32. Wal
ki
ng1/
2bl
ockonl
evelgr
ound(
nonst
op)
(
GC6WLGNS)
33. Maki
ngabed(
notc
hangi
ngsheet
s)
(
GC6MAKEB)
34. Cl
eani
ngwi
ndows
(
GC6CWI
ND)
35. Kneel
i
ng,s
quat
t
i
ngt
odol
i
ghtwor
k
(
GC6KNEEL)
36. Car
r
yi
ngal
i
ghtl
oadofgr
oc
er
i
es
(
GC6CARYL)
37. Cl
i
mbi
ngni
nes
t
eps(
nons
t
op)
(
GC6CBNSN)
38. Cl
i
mbi
ng12st
eps(
nonst
op)
(
GC6CBTSN)
39. Wal
ki
ng1/
2bl
ockuphi
l
l
(
GC6WUPHL)
40. Wal
ki
ng1/
2bl
ockuphi
l
l
(
nonst
op)
(
GC6WKUHN)
41. Shoppi
ng(
byy
our
sel
f
)
(
GC6SHOP)
42. Washi
ngcl
ot
hes(
byyour
sel
f
)
(
GC6WSHCT)
43. Wal
ki
ngonebl
oc
konl
evel
gr
ound
(
GC6WKOBK)
44. Wal
ki
ngt
wobl
oc
ksonl
ev
elgr
ound
(
GC6WKTBK)
45. Wal
ki
ngonebl
oc
konl
evel
gr
ound(
nonst
op)
(
GC6WOBNS)
46. Wal
ki
ngt
wobl
oc
ksonl
ev
elgr
ound
(
GC6WTBNS)
47. Scr
ubbi
ng(
f
l
oor
s,wal
l
sorcar
s)
(
GC6SCRUB)
1-St
i
l
lDoi
ngThi
s
Act
i
vi
t
y
48. Maki
ngbeds(
c
hangi
ngsheet
s)
(
GC6CHGST)
49. Sweepi
ng
(
GC6SWEEP)
50. Sweepi
ng(
f
i
vemi
nut
esnons
t
op)
(
GC6SWPNS)
51. Car
r
yi
ngal
ar
gesui
t
c
as
eorbowl
i
ng(
onel
i
ne)
(
GC6CSUI
T)
52. Vacuumi
ngcar
pet
s
(
GC6VACCM)
53. Vacuumi
ngcar
pet
s(
f
i
vemi
nut
esnons
t
op)
(
GC6VACFM)
54. Pai
nt
i
ng(
i
nt
er
i
or
/
ex
t
er
i
or
)
(
GC6PAI
NT)
55. Wal
ki
ngsi
xbl
ock
sonl
evel
gr
ound
(
GC6WSBGL)
56. Wal
ki
ngsi
xbl
ock
sonl
evel
gr
ound(
nonst
op)
(
GC6WSBNS)
57. Car
r
yi
ngoutt
hegar
bage
(
GC6GARBG)
58. Car
r
yi
ngaheavyl
oadofgr
oc
er
i
es
(
GC6HVYGR)
59. Cl
i
mbi
ng24st
eps
(
GC6TFSTP)
60. Cl
i
mbi
ng36st
eps
(
GC6TSSTP)
61. Cl
i
mbi
ng24st
eps(
nonst
op)
(
GC6TFNS)
62. Cl
i
mbi
ng36st
eps(
nonst
op)
(
GC6TSNS)
2-HaveSt
oppedDoi
ngThi
s
Act
i
vi
t
y
3-NeverDi
dThi
s
Act
i
vi
t
y
Not
Answer
ed
63. Wal
ki
ngonemi
l
e
(
GC6OMI
LE)
64. Wal
ki
ngonemi
l
e(
nonst
op)
(
GC6OMLNS)
65. Runni
ng110y
ar
ds(
100met
er
s)orpl
ay
i
ng
sof
t
bal
l
/
bas
ebal
l
(
GC6RUNYD)
66. Danci
ng(
soci
al
)
(
GC6DANCE)
67. Doi
ngcal
i
st
heni
csoraer
obi
cdanci
ng(
5mi
nut
es
nonst
op)
(
GC6EXCER)
68. Mowi
ngt
hel
awn(
powermower
,butnotar
i
di
ng
mower
)
(
GC6MOWLN)
69. Wal
ki
ngt
womi
l
es
(
GC62MI
LE)
70. Wal
ki
ngt
womi
l
es(
nonst
op)
(
GC6TMLNS)
71. Cl
i
mbi
ng50st
eps
(
GC6FSTPS)
72. Shov
el
i
ng,di
ggi
ngorspadi
ng
(
GC6DI
G)
73. Shov
el
i
ng,di
ggi
ngorspadi
ng(
f
i
vemi
nut
es
nonst
op)
(
GC6DI
GFM)
74. Cl
i
mbi
ng50st
eps(
nonst
op)
(
GC6CFSNS)
75. Wal
ki
ngt
hr
eemi
l
esorgol
f
i
ng18hol
eswi
t
houta
r
i
di
ngc
ar
t
(
GC63MI
LE)
76. Wal
ki
ngt
hr
eemi
l
es(
nons
t
op)
(
GC6TMI
LN)
77. Swi
mmi
ng25y
ar
ds
(
GC6SWI
M)
78. Swi
mmi
ng25y
ar
ds(
nonst
op)
(
GC6SWI
MN)
79. Bi
cyc
l
i
ngonemi
l
e
(
GC6BI
KE)
80. Bi
cyc
l
i
ngt
womi
l
es
(
GC6BI
KET)
81. Bi
cyc
l
i
ngonemi
l
e(
nonst
op)
(
GC6BKOMN)
82. Bi
cyc
l
i
ngt
womi
l
es(
nons
t
op)
(
GC6BKTMN)
83. Runni
ngorJoggi
ng1/
4mi
l
e
(
GC6RUNFM)
84. Runni
ngorJoggi
ng1/
2mi
l
e
(
GC6RUNHM)
85. Pl
ayi
ngt
enni
sorr
acquet
bal
l
(
GC6TENNS)
86. Pl
ayi
ngbas
ket
bal
l(
gamepl
ay)
(
GC6BBALL)
87. Runni
ngorj
oggi
ng1/
4mi
l
e(
nonst
op)
(
GC6RNFMN)
88. Runni
ngorj
oggi
ng1/
2mi
l
e(
nonst
op)
(
GC6RNHMN)
89. Runni
ngorj
oggi
ngonemi
l
e
(
GC6OMRUN)
90. Runni
ngorj
oggi
ngt
womi
l
es
(
GC6TMRUN)
91. Runni
ngorj
oggi
ngt
hr
eemi
l
es
(
GC6THRMR)
92. Runni
ngorj
oggi
ngonemi
l
ei
n12mi
nut
es
(
GC6TMMI
L)
93. Runni
ngorj
oggi
ngt
womi
l
esi
n20mi
nut
es
(
GC6TWMML)
94. Runni
ngorj
oggi
ngt
hr
eemi
l
esi
n30mi
nut
esorl
ess
(
GC6TRTMM)
Comment
s:
(
GC6COMM)
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on7-Pat
i
entcGVHD Sur
v
ey(
GC7)
WebVer
si
on:1.
0;2.
00;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on7:AboutYour
se
l
f
Des
cr
i
beyourcur
r
entwor
kst
at
usbychec
ki
ngoneboxperl
i
ne:
1.I
ns
chool
f
ul
lt
i
me:
(
GC7SCHFT)
1-Yes
2-No
3-NotAnswer
ed
2.I
ns
chool
par
tt
i
me:
(
GC7SCHPT)
1-Yes
2-No
3-NotAnswer
ed
3.Wor
ki
ngf
ul
l
t
i
me:
(
GC7WRKFT)
1-Yes
2-No
3-NotAnswer
ed
4.Wor
ki
ngpar
tt
i
me:
(
GC7WRKPT)
1-Yes
2-No
3-NotAnswer
ed
5.Homemaker
:
(
GC7HOME)
1-Yes
2-No
3-NotAnswer
ed
1-Yes
2-No
3-NotAnswer
ed
1-Yes
2-No
3-NotAnswer
ed
1-Yes
2-No
3-NotAnswer
ed
1-Yes
2-No
3-NotAnswer
ed
1-Yes
2-No
3-NotAnswer
ed
1-Yes
2-No
3-NotAnswer
ed
6.Ret
i
r
ed:
(
GC7RETI
R)
7.Onmedi
c
al
l
eavef
r
om wor
k:
(
GC7MEDLV)
8.Di
s
abl
ed,unabl
et
owor
k
:
(
GC7DI
SAB)
9.Unempl
oyed,l
ook
i
ngf
orwor
k:
(
GC7UNLK)
10.Unempl
oyed,notl
ooki
ngf
orwor
k
:
(
GC7UNNLK)
11.Ot
her
:
(
GC7WOTH)
12.Spec
i
f
yOt
her
:
(
GC7WOTSP)
13.Whati
sy
ourmar
i
t
als
t
at
us?(
GC7MRT)
I
fot
her
,s
peci
f
y:
(
GC7MRTOT)
14.Whati
st
hehi
ghestgr
adeofsc
hooly
ouhavecompl
et
ed?(
GC7HGGRD)
15.Whatwasyourappr
ox
i
mat
eannualf
ami
l
yi
ncomei
nt
hey
earbef
or
ey
ouhad
y
ourt
r
ans
pl
ant
?(
GC7ANI
NC)
Comment
s:
(
GC7COMM)
Addi
t
i
ona
lSel
ect
i
onOpt
i
onsf
orGC7
Whati
syourmar
i
t
alst
at
us?
88-NotAnswer
ed
Whati
st
hehi
ghestgr
adeofschoolyouhavecompl
et
ed?
6-Post
gr
aduat
edegr
ee
88-NotAnswer
ed
Whatwasyourappr
oxi
mat
eannualf
ami
l
yi
ncomei
nt
heyearbef
or
eyouhadyourt
r
anspl
ant
?
6-$100,
000orabove
88-NotAnswer
ed
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Funct
i
onalcGVHD Test
i
ng(
GFX)
WebVer
si
on:1.
0;1.
01;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
1.Dat
eofas
sessment
:
(
GFXASDT)
(
mm/
dd/
yy
yy)
TwoMi
nut
eWal
k
2.Tot
al
di
s
t
ancewal
kedi
nt
womi
nut
es:
(
GFX2MWLK)
(
xxx
.
x) f
t
Gr
i
pTest
Tr
i
al
Gr
i
pSt
r
engt
h(
l
b)
Gr
i
pSt
r
engt
h(
kg)
3. Tr
i
al#1: (
GFXGS1LB)
(
xxx
)l
b (
GFXGS1KG)
(
xx
) kg
4. Tr
i
al#2: (
GFXGS2LB)
(
xxx
)l
b (
GFXGS2KG)
(
xx
) kg
5. Tr
i
al#3: (
GFXGS3LB)
(
xxx
)l
b (
GFXGS3KG)
(
xx
) kg
6. Aver
age (
GFXGSALB)
(
xxx
)l
b (
GFXGSAKG)
(
xx
) kg
Schi
r
mer
'
sEyeExam
7.Ri
ghtEye(
OD)
:
(
GFXREYE)
(
x
x.
x
) mm
8.Lef
tEye(
OS)
:
(
GFXLEYE)
(
x
x.
x
) mm
Comment
s:
(
GFXCOMM)
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on1-Pr
ovi
dercGVHD Sur
v
ey(
GP1)
WebVer
si
on:1.
0;1.
04;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Dat
eofas
sessment
:
(
GP1STDT)
(
mm/
dd/
y
yyy)
Sect
i
on1:Ski
n
Der
mat
ol
ogi
cal
Sent
i
nelLesi
on
1. Head/
neck/
scal
p
(
GP1HNSSL)
Er
yt
hemat
ousr
as
hofany
sor
t
(
GP1ATRSL)
(
GP1HERS)
(
GP1HMS)
(
GP1HNMS)
1-Yes
(
GP1AERS)
(
GP1AMS)
(
GP1ANMS)
1-Yes
(
GP1PERS)
(
xx
x.
x
)%
(
GP1PMS)
(
xx
x.
x
)%
(
GP1PNMS)
(
xxx
.
x
)%
1-Yes
(
GP1LERS)
(
GP1LMS)
(
GP1LNMS)
1-Yes
(
GP1RERS)
(
xx
x.
x
)%
(
GP1RMS)
(
xx
x.
x
)%
(
GP1RNMS)
(
xxx
.
x
)%
1-Yes
(
GP1EERS)
(
xx
x.
x
)%
(
GP1EMS)
(
xx
x.
x
)%
(
GP1ENMS)
(
xxx
.
x
)%
1-Yes
(
GP1XERS)
(
GP1XMS)
(
GP1XNMS)
1-Yes
(
GP1GERS)
(
xx
x.
x
)%
(
GP1GMS)
(
xx
x.
x
)%
(
GP1GNMS)
(
xxx
.
x
)%
(
xx
x.
x
)%
(
xx
x.
x
)%
2-No
3. Post
er
i
ort
or
so
(
GP1PTRSL)
2-No
4. L.upperex
t
r
emi
t
y
(
GP1LUESL)
(
xx
x.
x
)%
2-No
5. R.upperex
t
r
emi
t
y
(
GP1RUESL)
2-No
6. L.l
owerex
t
r
emi
t
y
(
GP1LLESL)
2-No
7. R.l
owerex
t
r
emi
t
y
(
GP1RLESL)
(
xx
x.
x
)%
2-No
8. Geni
t
al
i
a(
GVP1GENT)
Ex
ami
ned
Not
(
GP1GENSL)
Nonmov
eabl
esubcut
aneous
scl
er
osi
sorf
asc
i
i
t
i
s
1-Yes
2-No
2. Ant
er
i
ort
or
s
o
Moveabl
es
cl
er
os
i
s
2-No
(
xx
x.
x
)%
(
xx
x.
x
)%
(
xx
x.
x
)%
(
xx
x.
x
)%
(
xxx
.
x
)%
(
xxx
.
x
)%
(
xxx
.
x
)%
(
xxx
.
x
)%
Ski
nscl
er
ot
i
cchanges
9.
0
1
2
3
4
(
GP1SKSCL)
Nor
mal
Thi
ckenedwi
t
hpock
et
sofnor
mal
s
ki
n
Thi
ck
enedovermaj
or
i
t
yof
sk
i
n
Thi
ckened,unabl
et
o
move
Hi
debound,unabl
et
o
pi
nc
h
Ski
nScor
e
10.
0
(
GP1SKSCR)
Sy
mpt
oms
No
1
2
3
<18% BSAwi
t
hdi
s
eas
e
si
gnsbutNO s
cl
er
ot
i
cf
eat
ur
es
1950% BSAORi
nv
ol
v
ementwi
t
hs
uper
f
i
ci
al
s
cl
er
ot
i
cf
eat
ur
esnothi
debound(
abl
et
opi
nch)
>50% BSAORdeeps
cl
er
ot
i
cf
eat
s.hi
debound
ORi
mpai
r
edmobi
l
i
t
y
,ul
c
er
at
i
onors
ev
er
epr
ur
i
t
i
s
Fasci
a
11.
0
(
GP1FASC)
1
Nor
mal
2
Ti
ghtwi
t
hnor
malar
eas
3
Ti
ght
Ti
ght
,unabl
et
omove
Cl
i
ni
calSki
nFeat
ur
es
12. Ul
cer
?(
GP1ULCRP)
2-No
1-Yes
13. Locat
i
on(
s
pec
i
f
y)
:
(
GP1ULCRL)
14. Lar
gestdi
mensi
on:
(
GP1ULCRD)
(
xx.
xx) c
m
15. Macul
opapul
arr
as
h
(
GP1MRASY)
1-Yes
2-No
16. Ker
at
osi
spi
l
ar
i
s
(
GP1KERPY)
1-Yes
2-No
17. Li
chenpl
anusl
i
kel
esi
ons (
GP1LI
CHY)
1-Yes
2-No
18. Papul
os
quamousl
esi
onsori
c
t
hyosi
s (
GP1PAPLY)
1-Yes
2-No
19. Poi
k
i
l
oder
ma
(
GP1POI
KY)
1-Yes
2-No
20. Hai
ri
nv
ol
v
ement
(
GP1HAI
RY)
1-Yes
2-No
21. Pr
ur
i
t
us
(
GP1PRURY)
2-No
22. Nai
l
i
nv
ol
v
ement
(
GP1NAI
LY)
1-Yes
2-No
23. Ot
her
(
GP1SKNFT)
2-No
24. Ot
her
,speci
f
y
:
(
GP1SKFOS)
Regi
on
Sent
i
nelLesi
on
25. Head,neckand (
GP1HNSL)
scal
p
2-No
1-Yes
1-Yes
1-Yes
Gr
ade(
seebel
ow)
0(
GP1HNS0G)
(
GP1HNS0P)
(
xxx
.
x) %
1-Yes
(
GP1HNS1P)
1-Yes
(
GP1HNS2P)
(
xxx
.
x) %
1-Yes
(
GP1HNS3P)
(
xxx
.
x) %
(
GP1HNS3A)
(
GP1HNS4P)
(
GP1HNS4A)
2-No
2(
GP1HNS2G)
2-No
3(
GP1HNS3G)
2-No
4(
GP1HNS4G)
1-Yes
2-No
(
xxx
.
x) %
(
xxx
.
x) %
TOTAL=
26. Chest
(
GP1CHSL)
1-Yes
2-No
(
GP1AG2SL)
1-Yes
2-No
(
GP1BBSL)
2-No
1-Yes
3/
4
0(
GP1CH0G)
2-No
1-Yes
(
GP1CH0P)
(
xxx
.
x) %
1(
GP1CH1G)
2-No
1-Yes
(
GP1CH1P)
0
1/
4
1/
2
0
1/
4
1/
2
1
1
2(
GP1CH2G)
2-No
1-Yes
(
GP1CH2P)
3(
GP1CH3G)
2-No
1-Yes
(
GP1CH3P)
4(
GP1CH4G)
2-No
1-Yes
(
xxx
.
x) %
(
xxx
.
x) %
(
xxx
.
x) %
(
GP1CH3A)
3/
4
(
GP1CH4P)
(
xxx
.
x) %
(
GP1CH4A)
3/
4
0
1/
4
1/
2
0
1/
4
1/
2
0
1/
4
1/
2
0
1/
4
1/
2
1
1
100%
0(
GP1AG0G)
2-No
1-Yes
(
GP1AG0P)
(
xxx
.
x) %
1(
GP1AG1G)
2-No
1-Yes
(
GP1AG1P)
2(
GP1AG2G)
2-No
1-Yes
(
GP1AG2P)
3(
GP1AG3G)
2-No
1-Yes
(
GP1AG3P)
4(
GP1AG4G)
2-No
1-Yes
(
xxx
.
x) %
(
xxx
.
x) %
(
xxx
.
x) %
(
GP1AG3A)
3/
4
(
GP1AG4P)
(
xxx
.
x) %
TOTAL=
28. Bac
kand
But
t
ocks
3/
4
100%
TOTAL=
27. Abdomenand
Geni
t
al
s
Fr
act
i
onofGr
ade3or4Ar
easwi
t
h
Er
yt
hema
1-Yes
2-No
1(
GP1HNS1G)
% Ar
eaofGr
ade
100%
0(
GP1BB0G)
2-No
1-Yes
(
GP1BB0P)
1(
GP1BB1G)
2-No
1-Yes
(
GP1BB1P)
2(
GP1BB2G)
2-No
1-Yes
(
GP1BB2P)
(
xxx
.
x) %
(
xxx
.
x) %
(
xxx
.
x) %
1
(
GP1AG4A)
3/
4
1
3(
GP1BB3G)
2-No
1-Yes
4(
GP1BB4G)
2-No
1-Yes
(
GP1BB3P)
(
xxx
.
x) %
29. Ri
ghtAr
m
(
GP1RASL)
2-No
1-Yes
(
GP1RHSL)
1-Yes
2-No
0(
GP1RA0G)
2-No
1-Yes
(
GP1RA0P)
(
GP1LASL)
2-No
1-Yes
1(
GP1RA1G)
2-No
1-Yes
(
GP1RA1P)
2(
GP1RA2G)
2-No
1-Yes
(
GP1RA2P)
3(
GP1RA3G)
2-No
1-Yes
(
GP1RA3P)
4(
GP1RA4G)
2-No
1-Yes
32. Lef
tHand
(
GP1LHSL)
2-No
1-Yes
0
1/
4
1/
2
0
1/
4
1/
2
0
1/
4
1/
2
0
1/
4
1/
2
0
1/
4
1/
2
0
1/
4
1/
2
0
1/
4
1/
2
0
1/
4
1/
2
0
1/
4
1/
2
1
(
xxx
.
x) %
(
xxx
.
x) %
(
GP1RA3A)
3/
4
(
GP1RA4P)
(
xxx
.
x) %
1
(
GP1RA4A)
3/
4
1
100%
1-Yes
(
GP1RH0P)
(
xxx
.
x) %
1(
GP1RH1G)
2-No
1-Yes
(
GP1RH1P)
2(
GP1RH2G)
2-No
1-Yes
(
GP1RH2P)
3(
GP1RH3G)
2-No
1-Yes
(
GP1RH3P)
4(
GP1RH4G)
2-No
1-Yes
(
xxx
.
x) %
(
xxx
.
x) %
(
xxx
.
x) %
(
GP1RH3A)
3/
4
(
GP1RH4P)
(
xxx
.
x) %
1
(
GP1RH4A)
3/
4
1
100%
0(
GP1LA0G)
2-No
1-Yes
(
GP1LA0P)
1(
GP1LA1G)
2-No
1-Yes
(
GP1LA1P)
(
xxx
.
x) %
2(
GP1LA2G)
2-No
1-Yes
(
GP1LA2P)
(
xxx
.
x) %
3(
GP1LA3G)
2-No
1-Yes
(
GP1LA3P)
(
xxx
.
x) %
(
GP1LA3A)
4(
GP1LA4G)
2-No
1-Yes
(
GP1LA4P)
(
GP1LA4A)
(
xxx
.
x) %
(
xxx
.
x) %
3/
4
3/
4
1
1
100%
0(
GP1LH0G)
2-No
1-Yes
(
GP1LH0P)
(
xxx
.
x) %
1(
GP1LH1G)
2-No
1-Yes
(
GP1LH1P)
(
xxx
.
x) %
2(
GP1LH2G)
2-No
1-Yes
(
GP1LH2P)
(
xxx
.
x) %
3(
GP1LH3G)
2-No
1-Yes
(
GP1LH3P)
(
xxx
.
x) %
(
GP1LH3A)
4(
GP1LH4G)
2-No
1-Yes
(
GP1LH4P)
(
xxx
.
x) %
(
GP1LH4A)
TOTAL=
1/
2
(
xxx
.
x) %
0(
GP1RH0G)
2-No
TOTAL=
1/
4
(
xxx
.
x) %
TOTAL=
31. Lef
tAr
m
(
GP1BB4A)
3/
4
0
1
100%
TOTAL=
30. Ri
ghtHand
3/
4
(
GP1BB4P)
(
xxx
.
x) %
TOTAL=
(
GP1BB3A)
100%
3/
4
3/
4
1
1
33. Ri
ghtLegand
Foot
(
GP1RLFSL)
1-Yes
2-No
0(
GP1RLF0G)
1-Yes
(
GP1RLF0P)
1-Yes
(
GP1RLF1P)
(
xxx
.
x) %
1-Yes
(
GP1RLF2P)
1-Yes
(
GP1RLF3P)
2-No
1(
GP1RLF1G)
2-No
2(
GP1RLF2G)
2-No
3(
GP1RLF3G)
2-No
4(
GP1RLF4G)
1-Yes
2-No
(
xxx
.
x) %
(
xxx
.
x) %
(
xxx
.
x) %
34. Lef
tLegand
Foot
(
GP1LLFSL)
1-Yes
2-No
0(
GP1LLF0G)
(
GP1LLF0P)
1-Yes
(
GP1LLF1P)
(
xxx
.
x) %
1-Yes
(
GP1LLF2P)
1-Yes
(
GP1LLF3P)
2-No
2(
GP1LLF2G)
2-No
3(
GP1LLF3G)
2-No
4(
GP1LLF4G)
1-Yes
2-No
(
xxx
.
x) %
1=di
scol
or
ed(
hy
popi
gment
at
i
on,hyper
pi
gment
at
i
on,al
opec
i
a,er
yt
hema,macul
opapul
arr
ash)
Comment
s:
(
GP1COMM)
0
1/
4
1/
2
0
1/
4
1/
2
0
1/
4
1/
2
1
(
GP1LLF3A)
3/
4
(
GP1LLF4P)
(
xxx
.
x) %
0=nor
mals
ki
n
4=hi
deboundski
n,unabl
et
omov
e,unabl
et
opi
nc
h
1/
2
(
xxx
.
x) %
Gr
adeDescr
i
pt
i
on
3=sk
i
nt
hi
ck
enedwi
t
hl
i
mi
t
edmot
i
onbutabl
et
opi
nch(
sc
l
er
oder
maorf
asci
aei
nvol
vement
)
1/
4
(
xxx
.
x) %
TOTAL=
2=l
i
chenoi
dpl
aque,ors
ki
nt
hi
ck
ened(
unabl
et
omove)
(
GP1RLF4A)
3/
4
0
1
100%
1-Yes
2-No
1(
GP1LLF1G)
3/
4
(
GP1RLF4P)
(
xxx
.
x) %
TOTAL=
(
GP1RLF3A)
100%
1
(
GP1LLF4A)
3/
4
1
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on2-Pr
ovi
dercGVHD Sur
v
ey(
GP2)
WebVer
si
on:1.
0;2.
00;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on2:ROM &Mout
h
Pl
easec
i
r
c
l
et
hi
sper
son'
scur
r
entROM f
oreachj
oi
ntf
r
om 1=poormot
i
l
i
t
yt
o7=f
ul
lmot
i
l
i
t
y
1. Shoul
der
(
GP2ROMSH)
1
2
3
4
5
6
7
2. El
bow
(
GP2ROMEL)
1
2
3
4
5
6
7
5
6
7
3. Wr
i
s
tandf
i
nger
s (
GP2ROMWF)
1
2
3
4
4. FootDor
si
f
l
ex
i
on (
GP2ROMFD)
1
2
3
4
0
1
2
3
5. Mout
hSc
or
e
(
GP2MTHSC)
NoSy
mpt
oms
Mi
l
dsympt
omswi
t
hdi
sease
si
gnsbutnotl
i
mi
t
i
ngor
ali
nt
ak
e
si
gni
f
i
cant
l
y
Moder
at
esy
mpt
omswi
t
h
Sev
er
es
ympt
omswi
t
hdi
seas
esi
gns
si
gnswi
t
hpar
t
i
all
i
mi
t
at
i
onofor
al onex
ami
nat
i
onwi
t
hmaj
orl
i
mi
t
at
i
onof
i
nt
ak
e
or
al
i
nt
ake
6. Er
yt
hema
(
GP2MTHER)
None
Mi
l
der
y
t
hemaORModer
at
e
er
y
t
hema(
<25%)
Moder
at
e(
≥25%)ORSever
e
er
yt
hema(
<25%)
Sev
er
eer
yt
hema(
≥25%)
7. Li
chenoi
d
(
GP2MTHLI
)
None
Hyper
k
er
at
ot
i
cc
hanges(
<25%)
Hyper
k
er
at
ot
i
cc
hanges
(
2550%)
Hyper
ker
at
ot
i
cchanges(
>50%)
8. Ul
c
er
s
(
GP2MTHUL)
None
None
Ul
c
er
si
nvol
vi
ng(
≤20%)
Sev
er
eul
cer
at
i
ons(
>20%)
9. Muc
oc
el
es(
ofl
ower (
GP2MTHMU)
l
abi
aands
of
tpal
at
e
None
onl
y
)
15mucocel
es
610sc
at
t
er
edmuc
oc
el
es
Ov
er10muc
oc
el
es
10. Mout
hPai
n
Foods
ens
i
t
i
vi
t
y
Pai
nr
equi
r
i
ngnar
c
ot
i
cs
Unabl
et
oeat
Comment
s:
(
GP2COMM)
(
GP2MTHPN)
Nos
ympt
oms
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on3-Pr
ovi
dercGVHD Sur
v
ey(
GP3)
WebVer
si
on:1.
0;2.
01;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on3:Gast
r
oi
nt
est
i
nal
0
1. GITr
actScor
e
(
GP3GI
TRT)
sy
mpt
oms
2. Esophagus
(
Dys
phagi
aOR
Ody
nophagi
a)
(
GP3GI
ESO)
No
esophagealsy
mpt
oms
3. UpperGI(
Ear
l
ysat
i
et
y (
GP3UPRGI
)
OR Anor
ex
i
aORNausea
sy
mpt
oms
&vomi
t
i
ng)
4. LowerGI(
Di
ar
r
hea)
Comment
s:
(
GP3COMM)
No
No
(
GP3LWRGI
)
No
l
ooseorl
i
qui
dst
ool
s
dur
i
ngt
hepastweek
1
2
3
Sympt
oms
:dy
sphagi
a,
anor
ex
i
a,nausea,vomi
t
i
ng,
abdomi
nal
pai
nordi
ar
r
heawi
t
h
wei
ghtl
oss(
<5%)
Sympt
omsass
oci
at
edwi
t
h
mi
l
dt
omoder
at
ewei
ghtl
oss
(
515%)
Sympt
omswi
t
hs
i
gni
f
i
c
ant
wei
ghtl
oss>15%,r
equi
r
es
nut
r
i
t
i
onals
uppl
ement
sOR
es
ophagealdi
l
at
i
on
Occasi
onaldysphagi
aor
odynophagi
aw/sol
i
df
oodorpi
l
l
s
I
nt
er
mi
t
t
entdysphagi
aor
odynophagi
awi
t
hsol
i
df
oodor
pi
l
l
s(
butnotf
orl
i
qui
ds/
sof
t
f
oods
)
Dysphagi
aorodynophagi
af
or
al
mostal
lor
al
i
nt
ake(
onal
most
ev
er
yday)
Mi
l
d,oc
casi
onal
sympt
omswi
t
h
l
i
t
t
l
er
educt
i
oni
nor
al
i
nt
ak
e
Moder
at
e,i
nt
er
mi
t
t
ent
s
ympt
omst
hr
oughoutt
heday,
s
omer
educt
i
oni
nor
ali
nt
ake
Mor
es
ev
er
eorper
si
s
t
ent
sympt
omst
hr
oughoutt
heday,wi
t
h
mar
kedr
educ
t
i
oni
nor
ali
nt
ake
Occasi
onall
oos
eorl
i
qui
d
st
ool
s
,ons
omedaysdur
i
ngt
he
pastweek
I
nt
er
mi
t
t
entl
oos
eorl
i
qui
d
s
t
ool
st
hr
oughoutt
heday,
wi
t
houtr
equi
r
i
ngi
nt
er
vent
i
on
Vol
umi
nousdi
ar
r
hea,onal
mos
t
ev
er
ydayoft
hepastweekr
equi
r
i
ng
i
nt
er
v
ent
i
on
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on4-Pr
ovi
dercGVHD Sur
v
ey(
GP4)
WebVer
si
on:1.
0;1.
02;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on4:Ot
herOr
gans
0
1
2
1. EyeSc
or
e
(
GP4EYESC)
Nosy
mpt
oms
Mi
l
ddr
yeyenotaf
f
ec
t
i
ngADL
OR asy
mpt
omat
i
csi
gnsofker
at
oconj
unc
t
i
vi
t
i
ssi
c
ca
2. J
oi
nt
sandFasc
i
aScor
e
(
GP4JOI
NT)
NoSympt
oms
Mi
l
dt
i
ght
nessofar
msorl
egs,
Ti
ght
nessofar
msorl
egs
nor
malr
angeofmot
i
on
ORj
oi
ntc
ont
r
ac
t
ur
es
,er
yt
hema
duet
of
as
ci
i
t
i
s,decr
eas
ei
nROM
Moder
at
edr
yey
epar
t
i
al
l
y
af
f
ect
i
ngADLWI
THOUTv
i
si
on
i
mpai
r
ment
3
Sev
er
edr
yeyesy
mpt
oms
si
gni
f
i
cant
l
yaf
f
ec
t
i
ngADLOR
unabl
et
owor
kORl
os
sofvi
s
i
on
Cont
r
act
ur
eswi
t
hsi
gni
f
i
c
ant
dec
r
eas
ei
nROM andsi
gni
f
i
c
ant
l
i
mi
t
at
i
onofADL
3. Geni
t
alTr
ac
tSc
or
e(
GP4GTSNA) (
GP4GENTT)
NoGYN Ex
am orN/
A(
mal
es)
Nosy
mpt
oms
Sy
mpt
omat
i
c
,mi
l
ddi
st
i
nct
si
gnsonex
am andnoef
f
ecton
coi
t
us,mi
ni
maldi
sc
omf
or
tw/GYN
ex
am
Sy
mpt
omat
i
c,di
st
i
nc
ts
i
gns
Sy
mpt
omat
i
c
,advanced
onex
am andmi
l
ddy
spar
euni
aor si
gns,sever
epai
nwi
t
hcoi
t
usor
di
s
comf
or
tw/GYN ex
am
i
nabi
l
i
t
yt
oi
ns
er
tvagi
nal
spect
r
um
4. LungScor
e
(
GP4LUNGS)
Nosy
mpt
oms
Mi
l
dsympt
oms(
s
hor
t
nes
sof
br
eat
haf
t
erc
l
i
mbi
ngonef
l
i
ghtof
st
eps)
Moder
at
es
ympt
oms
Sev
er
es
ympt
oms(
shor
t
ness
(
shor
t
nes
sofbr
eat
haf
t
erwal
k
i
ng ofbr
eat
hatr
est
;r
equi
r
i
ng
onf
l
atgr
ound)
ox
ygen)
5. Ot
herOr
ganSc
or
e(
s
pec
i
f
y
or
gan)
(
GP41OOSP)
(
GP4OR1OT)
Noef
f
ec
tonADL
Mi
l
def
f
ec
tonADL
Moder
at
eef
f
ectonADL
Sev
er
eef
f
ectonADL
6. Ot
herOr
ganSc
or
e(
s
pec
i
f
y
or
gan)
(
GP42OOSP)
(
GP4OR2OT)
Noef
f
ec
tonADL
Mi
l
def
f
ec
tonADL
Moder
at
eef
f
ectonADL
Sev
er
eef
f
ectonADL
Comment
s:
(
GP4COMM)
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on5-Pr
ovi
dercGVHD Sur
v
ey(
GP5)
WebVer
si
on:1.
0;2.
03;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on5:Over
al
lSt
at
us
1.Pl
easer
at
et
hesever
i
t
yoft
heper
s
on'
sc
hr
oni
cGVHD ont
het
woscal
esbel
ow:
a. (
GP5SCLA)
1-None
2-Mi
l
d
3-Moder
at
e
4-Sever
e
cGVHDsympt
omsar
enotatal
lsever
e<>cGVHD s
ympt
omsar
emostsever
easpos
si
bl
e
0
1
2
3
4
5
6
7
8
9
10
b. (
GP5SCLB)
2.Cur
r
entGVHD St
at
us:
(
GP5STATS)
Compl
et
eRespons
e
Par
t
i
al
Respons
e
Unchanged
3.Wast
her
apeut
i
cr
egi
menc
hanged?(
GP5TRCH)
1-Yes
I
fyes,i
ndi
c
at
ehow i
twaschangedbel
ow:
a. Adj
ustl
evel
sofmedi
c
at
i
on
(
GP5ADMED)
b. Enr
ol
l
oncl
i
ni
calt
r
i
al
(
GP5ENCT)
c. Wor
seni
ngofsy
mpt
oms
(
GP5WRSYM)
d. Noi
mpr
ovementi
nsy
mpt
oms (
GP5NI
SYM)
Pr
ogr
ess
i
ve
1-Yes
1-Yes
1-Yes
1-Yes
2-No
2-No
2-No
2-No
e. Tox
i
ci
t
y
(
GP5TOX)
f
. Newsympt
oms
(
GP5NESYM)
1-Yes
2-No
g. I
mpr
ov
ementi
nsympt
oms
(
GP5I
MSYM)
1-Yes
2-No
h. Di
s
eas
er
el
apse
(
GP5DSRLP)
1-Yes
2-No
i
. St
abl
e
(
GP5DSST)
1-Yes
2-No
2-No
1-Yes
2-No
4.Doest
hi
sper
s
oncur
r
ent
l
yhave:
(
GP5GVHOS)
5.Si
ncet
hel
astvi
si
t
,how woul
dy
ousayt
heper
s
on'
sc
hr
oni
cGVHD haschanged?
Noti
nvol
ved
a. Mout
h
(
GP5MTHCH)
b. Ski
n
(
GP5SKNCH)
Resol
ved
Ver
ymuch
bet
t
er
Moder
at
el
y
bet
t
er
Al
i
t
t
l
e
bet
t
er
Aboutt
he
same
Al
i
t
t
l
e
wor
se
Moder
at
el
y
wor
se
Ver
ymuch
wor
se
c. Eyes
(
GP5EYECH)
d. J
oi
nt
s
(
GP5JNTCH)
e. Chr
oni
c
GVHDover
al
l
(
GP5CGVCH)
f
.Whatar
eyourr
eas
onsf
orhowyour
at
ed"
chr
oni
cGVHDover
al
l
"
?(
GP5CGVRS)
6.Sent
i
nelOr
gan
I
ndi
cat
ewhi
chor
gansy
st
em wi
l
lgui
dey
ourt
r
eat
mentdeci
si
ons.(
I
fmor
et
hanone,pl
eas
er
ankwi
t
h1bei
ngf
i
r
stand4bei
ngl
ast
)
.
a. Ski
n
(
GP5TDSKN)
0-No,wi
l
l
notgui
de
1
2
3
4
b. J
oi
nt
s
(
GP5TDJNT)
0-No,wi
l
l
notgui
de
1
2
3
4
c. Fasc
i
a
(
GP5TDFAS)
0-No,wi
l
l
notgui
de
1
2
3
4
d. Lung
(
GP5TDLNG)
0-No,wi
l
l
notgui
de
1
2
3
4
e. Ur
ogeni
t
al
(
GP5TDURO)
0-No,wi
l
lnotgui
de
1
2
3
4
f
. Li
ver
(
GP5TDLI
V)
1
2
3
4
g. Mout
h
(
GP5TDMTH)
0-No,wi
l
lnotgui
de
1
2
3
4
h. Esophagus
(
GP5TDESP)
0-No,wi
l
lnotgui
de
1
2
3
4
i
. LowerGI
(
GP5TDLGI
)
1
2
3
4
j
. Ot
her
(
GP5TDOTH)
1
2
3
4
k. Speci
f
yot
her
: (
GP5TDOSP)
Comment
s:
(
GP5COMM)
0-No,wi
l
l
notgui
de
0-No,wi
l
l
notgui
de
0-No,wi
l
lnotgui
de
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on6-Pr
ovi
dercGVHD Sur
v
ey(
GP6)
WebVer
si
on:1.
0;1.
02;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on6:Ot
heri
ndi
c
at
or
s
,cl
i
ni
calmani
f
est
at
i
onsorsever
ecompl
i
c
at
i
onsr
e
l
a
t
edt
oc
hr
oni
cGVHD
Ot
heri
ndi
cat
or
s,cl
i
ni
calmani
f
est
at
i
onsorsever
ec
ompl
i
cat
i
onsr
el
at
edt
ochr
oni
cGVHD
Never(
0)
1. Pl
eur
al
Ef
f
usi
on(
s)
(
GP6OI
PLE)
2. Br
onchi
ol
i
t
i
sobl
i
t
er
ans
(
GP6OI
BO)
3. Br
onchi
ol
i
t
i
sobl
i
t
er
ansor
gani
z
i
ngpneumoni
a
(
GP6OI
BOP)
4. Nephr
ot
i
csyndr
ome
(
GP6OI
NS)
5. Mal
absor
pt
i
on
(
GP6OI
MAL)
6. Esophageals
t
r
i
ct
ur
eorweb
(
GP6OI
ESW)
7. Asci
t
es(
ser
osi
t
i
s
)
(
GP6OI
ASC)
8. My
ast
heni
aGr
avi
s
(
GP6OI
MG)
9. Per
i
pher
alNeur
opat
hy
(
GP6OI
PN)
10. Pol
ymyosi
t
i
s
(
GP6OI
PM)
11. Per
i
c
ar
di
alEf
f
usi
on
(
GP6OI
PCE)
12. Car
di
omy
opat
hy
(
GP6OI
CAR)
13. Car
di
acc
onduct
i
ondef
ect
s
(
GP6OI
CCD)
14. Cor
onar
yar
t
er
yi
nvol
vement
(
GP6OI
CAI
)
15. Ot
her1,pl
eases
pec
i
f
y:
(
GP6OT1SP)
(
GP6OI
1OT)
Ot
her2,pl
eases
peci
f
y:
(
GP6OT2SP)
(
GP6OI
2OT)
Ot
her3,pl
eases
peci
f
y:
(
GP6OT3SP)
(
GP6OI
3OT)
0
16.
I
nf
ect
i
on
(
GP6I
NF)
None
Past
,notnow (
1) Mi
l
d(
2) Moder
at
e(
3) Sever
e(
4)
0-
I
f2,3,or4,t
hen
s
el
ec
tone:
1
2
1-Mi
l
d,t
opi
calorno
t
her
apyr
equi
r
ed
2-Moder
at
e,l
oc
al
i
z
ed,
r
equi
r
i
ngor
alt
r
eat
ment
(
GP6I
NFSP)
Pendi
ngLabRepor
t
3
Uni
dent
i
f
i
edor
gani
sm
3-Sev
er
e,sy
st
emi
ci
nf
ec
t
i
onr
equi
r
i
ngI
V
ant
i
i
nf
ec
t
i
ve,mol
dact
i
v
eor
al
ant
i
f
ungalor
hos
pi
t
al
I
dent
i
f
i
edor
gani
s
m
Speci
f
yor
gani
sm:
(
GP6ORGSP)
17. Per
i
pher
al
Edema? (
GP6PERED)
Comment
s:
(
GP6COMM)
0-None
9-Tr
ace
1+
2+
3+
4+
4
4Li
f
et
hr
eat
eni
ng
i
nf
ect
i
on
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on1-Pedi
at
r
i
ccGVHD Sur
v
ey(
GV1)
WebVer
si
on:1.
0;1.
00;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on1:YourChr
oni
cGr
af
tvs.Hos
tDi
se
ase(
GVHD)Sympt
oms
Dat
eofas
sessment
:
(
GV1ASDT)
(
mm/
dd/
yyy
y)
Pl
eas
esel
ectt
henumbert
hatshowshowsever
eyours
ympt
omshavebeeni
nt
hel
astweek
wi
t
h0r
epr
esent
i
ng'
NotPr
es
ent
'and10r
epr
es
ent
i
ng'
AsBadAsYouCanI
magi
ne'
:
0
1
2
3
4
5
6
7
8
9
10 NotAnswer
ed
1. Yourchr
oni
cGVHDsy
mpt
omsover
al
l
? (
GV1CGVHD)
2. Yourski
ni
t
chi
ngati
t
sWORST?
(
GV1SKI
N)
3. Yourmout
hdr
ynessati
t
sWORST?
4. Yourmout
hpai
nati
t
sWORST?
(
GV1MTDRY)
(
GV1MTPN)
5. Yourmout
hsensi
t
i
vi
t
yati
t
sWORST? (
GV1MTSEN)
6. Youreyepr
obl
em ati
t
sWORST?
(
GV1EYE)
7.Whati
syourmai
nc
ompl
ai
ntwi
t
hr
egar
dt
oyoureyes?(
GV1EYECO)
8.Over
al
l
,howwoul
dyour
at
et
hesever
i
t
yofy
ourc
hr
oni
cgr
af
tv
shostdi
sease?
(
GV1SGVHD)
9.Doyout
hi
nkyourchr
oni
cGVHDsy
mpt
omsar
ei
ngoodenoughc
ont
r
ol
t
o
decr
easey
ouri
mmunos
uppr
essi
vemedi
cat
i
ons?(
GV1DMED)
0-Noti
nvol
ved
wi
t
hGVHD
10. GVHD
Sympt
oms
Over
al
l
:
-
11. Mout
h:
(
GV1MOUTH)
12. Ski
n:
(
GV1SKN)
13. Eye:
(
GV1EYESX)
14. Joi
nt
s
:
(
GV1JNTS)
Comment
s:
(
GV1COMM)
1-Compl
et
el
y
gone
(
GV1OGVHD)
2-Ver
y
much
bet
t
er
1-Yes
3-Moder
at
el
y
bet
t
er
2-No
4-A
l
i
t
t
l
e
bet
t
er
3-N/
A
5-About
t
hesame
6-A
l
i
t
t
l
e
wor
se
4-NotAnswer
ed
7Moder
at
el
y
wose
8-Ver
y
much
wor
se
Not
Answer
ed
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on2-Pedi
at
r
i
ccGVHD Sur
v
ey(
GV2)
WebVer
si
on:1.
0;1.
00;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on2:Det
ai
l
sofYourChr
oni
cGVHDSympt
oms
Pl
eas
esel
ectt
henumbert
hati
ndi
c
at
eshow muc
hyouhavebeenbot
her
edbyt
hef
ol
l
owi
ngpr
obl
emsi
nt
hel
ast4weeks
:
SKI
N:
0-Notatal
l
1-Sl
i
ght
l
y 2-Moder
at
el
y 3-Qui
t
eA Bi
t 4-Ext
r
emel
y NotAnswer
ed
1. Abnor
mal
ski
nc
ol
or (
GV2ABNSK)
2. Ras
hes
(
GV2RASH)
3. Thi
ckenedsk
i
n
(
GV2THSKN)
4. Sor
esons
ki
n
(
GV2SKSOR)
5. I
t
chys
ki
n
(
GV2I
TCSK)
EYESAND MOUTH:
0-NotAtAl
l
6. Dr
yeyes
(
GV2EYEDR)
7. Needt
ouseeyedr
opsf
r
equent
l
y
(
GV2EDFRQ)
8. Di
f
f
i
cul
t
ys
eei
ngcl
ear
l
y
(
GV2DI
FSE)
9. Needt
oavoi
dcer
t
ai
nf
oodsduet
omout
hpai
n
10. Ul
c
er
si
nmout
h
1Sl
i
ght
l
y
2Moder
at
el
y
3-Qui
t
eA
Bi
t
4Ext
r
emel
y
(
GV2AFOOD)
(
GV2ULCER)
11. Recei
vi
ngnut
r
i
t
i
onf
r
omani
nt
r
av
enousl
i
neorf
eedi
ng
t
ube
(
GV2NUTR)
BREATHI
NG:
0-NotAtAl
l
12. Fr
equentcough
(
GV2FRQCH)
13. Col
or
edsput
um
(
GV2COLOR)
1-Sl
i
ght
l
y 2-Moder
at
el
y 3-Qui
t
eABi
t 4-Ext
r
emel
y NotAnswer
ed
14. Shor
t
nes
sofbr
eat
hwi
t
hex
er
ci
se (
GV2SOBEX)
15. Shor
t
nes
sofbr
eat
hatr
est
(
GV2SOBRT)
16. Needt
ous
eox
ygen
(
GV2NDOX)
EATI
NG ANDDI
GESTI
ON:
0-NotAtAl
l
17. Di
f
f
i
cul
t
yswal
l
owi
ngsol
i
df
oods (
GV2DSSF)
18. Di
f
f
i
cul
t
yswal
l
owi
ngl
i
qui
ds
(
GV2DSLD)
1-Sl
i
ght
l
y 2-Moder
at
el
y 3-Qui
t
eA Bi
t 4-Ext
r
emel
y NotAnswer
ed
Not
Answer
ed
19. Vomi
t
i
ng
(
GV2VOMI
T)
20. Wei
ghtl
oss
(
GV2WTLS)
MUSCLESANDJOI
NTS:
0-NotAtAl
l
21. Joi
ntandmusc
l
eac
hes
(
GV2JI
ONT)
22. Li
mi
t
edj
oi
ntmovement
(
GV2LTJTM)
23. Musc
l
ecr
amps
(
GV2MUSCR)
24. WeakMuscl
es
(
GV2WKMUS)
1-Sl
i
ght
l
y 2-Moder
at
el
y 3-Qui
t
eA Bi
t 4-Ext
r
emel
y NotAnswer
ed
ENERGY:
0-NotAtAl
l
25. Lossofener
gy
1-Sl
i
ght
l
y 2-Moder
at
el
y 3-Qui
t
eABi
t 4-Ext
r
emel
y NotAnswer
ed
(
GV2LSERG)
26. Needt
osl
eepmor
e/
t
ak
enaps (
GV2SLEEP)
27. Fever
s
(
GV2FEVER)
MENTALANDEMOTI
ONAL:
0-NotAtAl
l
28. Depr
essi
on
29. Anx
i
et
y
(
GV2DEPRS)
(
GV2ANXY)
30. Di
f
f
i
cul
t
ysl
eepi
ng (
GV2DFSLP)
Comment
s:
(
GV2COMM)
1-Sl
i
ght
l
y 2-Moder
at
el
y 3-Qui
t
eABi
t 4-Ext
r
emel
y NotAnswer
ed
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on3-Pedi
at
r
i
ccGVHD Sur
v
ey(
GV3)
WebVer
si
on:1.
0;1.
00;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on3:YourHea
l
t
handWel
l
Bei
ng
1.Whi
c
hst
at
ementdesc
r
i
beshowyouf
eel
mostoft
het
i
me?(
pl
eas
echeck
one)
(
GV3FLMST)
Comment
s:
(
GV3COMM)
Addi
t
i
ona
lSel
ect
i
onOpt
i
onsf
orGV3
Whi
chst
at
ementdescr
i
beshow youf
eelmostoft
het
i
me?(
pl
easecheckone)
6-Get
sdr
es
sedbutl
i
ear
oundmuchofday,noact
i
vepl
aybutabl
et
ot
akepar
ti
nqui
etpl
ay
7-Mos
t
l
yi
nbed;par
t
i
ci
pat
esi
nqui
etac
t
i
vi
t
i
es
8-I
nbed;needsass
i
st
anceev
enf
orqui
etpl
ay
9-Of
t
ensl
eepi
ng;pl
ayent
i
r
el
yl
i
mi
t
edt
ov
er
ypassi
v
eact
i
vi
t
i
es
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
t
i
on4-Pedi
at
r
i
ccGVHD Sur
v
ey(
GV4)
WebVer
si
on:1.
0;1.
00;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on4:Ac
t
i
vi
t
i
esScal
e
Lastweek.
.
.
1.I
putt
oot
hpast
eon
myt
oot
hbr
usht
hen
br
ushedmyt
eet
hby
mys
el
f
.
.
.
(
GV4BRTTH)
2.I
usedt
het
oi
l
etat
homebymys
el
f
.
.
.
(
i
nc
l
udesget
t
i
ngon
andof
ft
het
oi
l
et
)
(
GV4TOI
LT)
3.I
washedmywhol
e
bodybymys
el
f
.
.
.
(
GV4WSHWB)
4.I
putmyshi
r
tonby
mys
el
f
.
.
.
(
GV4SHI
RT)
5.I
putmypant
sonby
mys
el
f
.
.
.
(
GV4PANTS)
6.I
f
ast
enedmy
cl
ot
hesbymysel
f
.
.
.
(
f
as
t
enedmeans
doi
ngupbut
t
onsand
z
i
pper
s)
(
GV4FSCLT)
(
GV4NOFST)
Or
Idi
dnotneedt
obec
ausenoneofmycl
ot
heshav
ef
ast
ener
s
7.I
putmyshoeson
anddi
dt
hem upby
mys
el
f
.
.
.
(
GV4SHOES)
(
GV4NOSHE)
Or
(
GV4NSHEX)
Expl
ai
n:
Idi
dnotneedt
owearshoesl
as
tweek
8.I
madeasnackby
mys
el
f(
orpr
epar
ed
br
eakf
astorl
unch)
.
.
.
(
GV4SNACK)
(
GV4NOSNK)
Or
Iwasnotal
l
owedt
osnackormakemyownmeal
s
9.I
di
dmyusualj
obor
chor
es.
.
.
(
Exampl
es:paper
r
out
e,babys
i
t
t
i
ng,
doi
ngt
hedi
shes)
(
GV4USLJB)
(
GV4NOJ
OB)
Or
Idon'
thaveaj
oborchor
es
Or
Idi
dnothavespeci
almedi
calneedsl
astweek
10.I
t
ookcar
eofmy
medi
calneeds.
.
.
(
Exampl
es:puton
s
pl
i
nt
sort
ook
medi
c
at
i
on)
(
GV4MEDCL)
(
GV4NOMED)
11.I
di
dmypr
i
nt
i
ng(
or
s
cr
i
ptwr
i
t
i
ng)by
mys
el
f
.
.
.
(
Exampl
es:t
odomy
s
chool
wor
k)
(
GV4PRI
NT)
12.I
di
dt
hesamespor
t
s
t
hatIusual
l
yenj
oyby
mysel
f
.
.
.
(
Exampl
es:
Gymnast
i
cs
,j
ungl
e
gym,dance,bi
cyc
l
i
ng,
s
wi
mmi
ng)
(
GV4SPORT)
13.I
wal
kedwi
t
houtany
suppor
t
.
.
.
(
No
c
r
ut
chesorc
anes)
(
GV4NOSUP)
14.Togetar
oundI
NSI
DEIusual
l
yused.
.
.
(
pl
eas
echooseasmanyoft
heseasyouus
e)
nos
pec
i
al
suppor
t
:
(
GV4I
SPLS)
1-Yes
2-No
3-NotAns
wer
ed
anar
t
i
f
i
ci
all
eg(
or
l
egs)
:
(
GV4I
ARLG)
1-Yes
2-No
3-NotAns
wer
ed
one
c
ane:
(
GV4I
1CAN)
1-Yes
2-No
3-NotAns
wer
ed
t
wocanes:
(
GV4I
2CAN)
1-Yes
2-No
3-NotAns
wer
ed
c
r
ut
ches:
(
GV4I
CRUT)
1-Yes
2-No
3-NotAns
wer
ed
myhandsand
k
nees:
(
GV4I
HDKN)
1-Yes
2-No
3-NotAns
wer
ed
awal
k
er
:
(
GV4I
WLKR)
1-Yes
2-No
3-NotAns
wer
ed
awheel
chai
r
:
(
GV4I
WLCH)
1-Yes
2-No
3-NotAns
wer
ed
ascoot
er
:
(
GV4I
SCOT)
1-Yes
2-No
3-NotAns
wer
ed
br
ace,spl
i
ntor
or
t
hosi
s
:
(
GV4I
BRCE)
1-Yes
2-No
3-NotAns
wer
ed
ot
her
:
(
GV4I
NSOT)
1-Yes
2-No
3-NotAns
wer
ed
pl
eas
edescr
i
be
ot
her
:
(
GV4I
NSOS)
15.I
gotar
oundi
nsi
de
myhomewi
t
hout
anyonet
ohel
pme.
.
.
(
Exampl
es:wal
kedor
wheel
edt
ot
he
bat
hr
oom,t
ot
he
di
nnert
abl
e,ort
ot
he
k
i
t
c
henf
oradr
i
nk)
(
GV4I
NOHP)
16.I
wal
ked(
orwheel
ed)
i
ncr
owdedar
eas.
.
.
(
Exampl
es:s
chool
hal
l
waysbet
ween
c
l
assesoratabus
y
s
hoppi
ng
mal
l
)
(
GV4CROWD)
(
GV4AWCRW)
Or
It
r
i
edt
ost
ayawayf
r
om c
r
owds
17.Togetar
oundOUTSI
DEIusual
l
yused.
.
.
(
pl
eas
echooseasmanyoft
heseasyouus
e)
nos
pec
i
al
suppor
t
:
(
GV4OSPLS)
1-Yes
2-No
3-NotAns
wer
ed
anar
t
i
f
i
ci
all
eg(
or
l
egs)
:
(
GV4OARLG)
1-Yes
2-No
3-NotAns
wer
ed
one
c
ane:
(
GV4O1CAN)
1-Yes
2-No
3-NotAns
wer
ed
t
wocanes:
(
GV4O2CAN)
1-Yes
2-No
3-NotAns
wer
ed
c
r
ut
ches:
(
GV4OCRUT)
1-Yes
2-No
3-NotAns
wer
ed
myhandsand
k
nees:
(
GV4OHDKN)
1-Yes
2-No
3-NotAns
wer
ed
awal
k
er
:
(
GV4OWLKR)
1-Yes
2-No
3-NotAns
wer
ed
awheel
chai
r
:
(
GV4OWLCH)
1-Yes
2-No
3-NotAns
wer
ed
ascoot
er
:
(
GV4OSCOT)
1-Yes
2-No
3-NotAns
wer
ed
br
ace,spl
i
ntor
or
t
hosi
s
:
(
GV4OBRCE)
1-Yes
2-No
3-NotAns
wer
ed
ot
her
:
(
GV4OUTOT)
1-Yes
2-No
3-NotAns
wer
ed
pl
eas
edescr
i
be
ot
her
:
(
GV4OUTOS)
18.I
gotar
oundout
si
de
wi
t
houtanyonet
o
hel
pme.
.
.
(
Exampl
es:wal
kedor
wheel
edt
oaf
r
i
end'
s
house,t
osc
hool
,ort
o
t
hepar
k)
(
GV4NOHLP)
(
GV4NOOUT)
Or
(
GV4NOOTE)
Expl
ai
n:
Inev
erhadt
hechancet
ogoout
si
del
as
tweek
19.I
wal
ked(
orwheel
ed)
upagent
l
ehi
l
lor
s
l
opebymy
sel
f
.
.
.
(
GV4GHI
LL)
(
GV4AWHI
L)
Or
Ial
wayst
r
i
edt
os
t
ayawayf
r
om hi
l
l
s
20.I
wal
ked(
orwheel
ed)
onr
oughorsl
i
pper
y
sur
f
aces.
.
.
(
Exampl
es:gr
avel
dr
i
v
eway
s,orwet
s
i
dewal
ks
)
(
GV4RGHSP)
(
GV4NORGH)
Or
Idi
dnotneedt
o,Idi
dnotcomeacr
ossar
oughorsl
i
pper
ysur
f
ace
21.WhenIr
an(
or
wheel
ed)ar
ound
out
s
i
de,Ikeptupwi
t
h
myf
r
i
ends
.
.
.
(
GV4KPTUP)
(
GV4NOFRD)
Or
(
GV4NOFRE)
Expl
ai
n:
Idi
dnothaveachanc
et
obeout
si
dewi
t
hf
r
i
ends
Howmuc
hhel
phave
y
ouhads
o
f
ar
?(
GV4HELP)
Pl
easedescr
i
be:
(
GV4HLPDS)
22.I
car
r
i
edadr
i
nkor
f
oodt
ot
het
abl
eby
mys
el
fwi
t
hout
s
pi
l
l
i
ng.
.
.
(
GV4CRDRK)
(
GV4NODRK)
Or
Iam notal
l
owedt
odot
hi
s
Or
Ihadnor
easont
ocar
r
yanyt
hi
ngi
n2handsl
astweek
23.I
car
r
i
edt
hi
ngsi
n2
handsbymy
sel
f
.
.
.
(
Exampl
es:bi
gor
heavyt
hi
ngsl
i
k
e
s
t
uf
f
edani
mal
s,
f
ami
l
y
pet
)
(
GV4CRDTH)
(
GV4NOCRD)
24.I
st
oodst
i
l
lf
or10
mi
nut
eswi
t
hout
r
est
i
ng.
.
.
(
Exampl
es:wai
t
i
ngi
n
l
i
neatt
hest
or
e)
(
GV4STSTL)
25.I
st
r
et
chedt
or
each
ahi
ghshel
f(
ort
os
ee
overt
heper
s
oni
n
f
r
ontofme)
.
.
.
(
GV4REACH)
(
GV4NORCH)
Or
Idi
dnotneedt
ost
r
et
c
hf
oranyt
hi
ng
Or
Idi
dnotneedt
o,becauseIdi
dnotcomeacr
ossaf
l
i
ghtofs
t
ai
r
s
Or
Idi
dn'
tneedt
ogoany
wher
ebyaut
omobi
l
el
astweek
Or
Idi
dnothaveanyr
eas
ont
os
i
tont
hef
l
oor
26.I
gott
hr
oughheavy
door
sbymysel
f
.
.
.
(
Exampl
es:t
hef
r
ont
doorathomeorat
s
chool
)
(
GV4HVDOR)
27.I
wal
kedupand
downaf
l
i
ghtof
st
ai
r
s(
ev
enwhen
ot
herpeopl
ewer
e
usi
ngt
hem)
.
.
.
(
Not
e:onef
l
i
ghti
s
about14s
t
ai
r
s)
(
GV4STAI
R)
(
GV4NOSTR)
28.I
goti
nandoutofan
aut
omobi
l
eby
mys
el
f
.
.
.
(
openedt
hedoor
,got
i
n,c
l
osedt
hedoor
,
andgotoutagai
n)
(
GV4AUTMB)
(
GV4NOAUT)
29.I
goti
nandoutofa
chai
r(
orwheel
chai
r
)
bymy
sel
f
.
.
.
(
GV4CHAI
R)
30.I
satont
hef
l
oor
.
.
.
(
Exampl
es:ata
s
choolassembl
yor
wat
chi
ng
TV)
(
GV4STFLR)
(
GV4NOFLR)
31.I
goti
nandoutofmy
bedbymysel
f
.
.
.
(
GV4I
OBED)
32.I
gotdownont
ot
he
gr
oundf
r
om
st
andi
ng,andgot
backupagai
nby
mys
el
f
.
.
.
(
GV4GRSTD)
(
GV4NOGRD)
Or
(
GV4GRDEX)
Expl
ai
n:
Idi
dnotneedt
ogetont
ot
hef
l
oororgr
ound
33.Idi
dcl
i
mbi
ng
act
i
vi
t
es.
.
.
(
Exampl
es:c
l
i
mbi
ng
t
r
ees,r
ock
s,or
c
l
i
mbi
ngoveraf
ence)
(
GV4CLI
MB)
(
GV4NOCLM)
Or
Idi
dnotdocl
i
mbi
ngact
i
vi
t
i
es
Or
Idi
dnotpl
ays
por
t
si
ncl
ass
Or
Idi
dnotpl
ays
por
t
s
Or
Idi
dnotpl
ays
por
t
si
ncompet
i
t
i
vel
eagues
Or
Idi
dnotpl
ayr
oughgames
Or
Idi
dnotdot
hes
eact
i
vi
t
i
es
34.Ipl
ayedt
eam spor
t
s
wi
t
hot
her
si
nmy
c
l
as
s.
.
.
(
Exampl
es:
basket
bal
l
,bas
ebal
l
,
s
oc
cer
,hock
ey
)
(
GV4TMSPT)
(
GV4NOSPT)
35.Ipl
ayedsome
spor
t
sbymysel
for
wi
t
haf
ew f
r
i
ends.
.
.
(
Exampl
es:dr
i
bbl
i
ng
andshoot
i
nga
basket
bal
l
)
(
GV4SPTMS)
(
GV4NOSMS)
36.I
pl
ayeds
omespor
t
s
i
ncompet
i
t
i
ve
l
eagues.
.
.
(
Exampl
es:wi
t
ha
l
oc
albask
et
bal
l
,
basebal
l
,soc
cer
,or
hockey
t
eam)
(
GV4SPTCL)
(
GV4NOSCL)
37.I
keptmybal
ance
whi
l
epl
ayi
ngr
ough
games
.
.
.
(
Exampl
es:t
ag,
wr
est
l
i
ng,kar
at
e,
j
udo)
(
GV4BALNC)
(
GV4NOGMS)
38.I
di
dact
i
vi
t
i
esI
usual
l
yenj
oyf
ora
l
ongt
i
mewi
t
hout
get
t
i
ngt
i
r
edout
.
.
.
(
Exampl
es:
s
wi
mmi
ng,j
oggi
ng,
t
enni
s
,badmi
nt
on,
r
owi
ng,sk
i
i
ng)
(
GV4NOTRD)
(
GV4NOACT)
39.I
r
ani
nar
ace.
.
.
(
Exampl
es:100met
er
dash)
(
GV4RACE)
(
GV4NORAC)
Or
Idi
dnotr
uni
nr
aces
Or
Idi
dnotwor
kwi
t
hmyhands
40.I
wor
kedcar
ef
ul
l
y
wi
t
hmyhands.
.
.
(
Exampl
es:bui
l
di
ng
wi
t
hLego,mak
i
ng
model
s
,s
ewi
ng,
mak
i
ngbead
neckl
aces)
(
GV4WRKHD)
(
GV4NOWRK)
Comment
s:
(
GV4COMM)
Addi
t
i
ona
lSel
ect
i
onOpt
i
onsf
orGV4
Iputt
oot
hpast
eonmyt
oot
hbr
usht
henbr
ushedmyt
eet
hbymysel
f
.
.
.
Notanswer
ed
Iwal
ked(
orwheel
ed)onr
oughorsl
i
pper
ysur
f
aces.
.
.
(
Ex
ampl
es:gr
aveldr
i
veways,orwetsi
dewal
ks)
Notanswer
ed
How muchhel
phaveyouhadsof
ar
?
Notanswer
ed
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Se
ct
i
on5:Pedi
at
r
i
cc
GVHD Sur
ve
y(
GV5)
WebVer
si
on:1.
0;1.
00;121115
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Sect
i
on5:AboutYour
s
el
f
Des
cr
i
beyourcur
r
entwor
kst
at
usbychecki
ngoneboxperl
i
ne.
1.I
nschoolf
ul
lt
i
me(
GV5SCHFT)
2.I
nschoolpar
tt
i
me(
GV5SCHPT)
3.Wor
k
i
ngf
ul
lt
i
me(
GV5WKFT)
4.Wor
k
i
ngpar
tt
i
me(
GV5WKPT)
5.Notgoi
ngt
os
chool
orwor
ki
ngduet
owor
kst
at
us
(
GV5NOSW)
6.Ot
her
(
GV5OTH)
7.Speci
f
yot
her
:
(
GV5OTHSP)
Comment
s:
(
GV5COMM)
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
I
nf
ec
t
i
onFor
m(
I
NF)
WebVer
si
on:1.
0;4.
01;101615
Segment(
PROTSEG)
:
I
nf
ect
i
onSi
t
e(
I
NFSI
TE)
:
I
nf
ect
i
onSt
ar
tDat
e(
I
NFSTDT)
:
I
NFECTI
ON I
1.Typeofi
nf
ect
i
on:
(
I
NFTYP01)
2.Or
gani
smI
:
(
ORGN01)
?
I
fot
herspeci
f
y
:
(
I
NFSPEC1)
3.Recor
dt
hel
ev
el
ofc
er
t
ai
nt
yoft
hef
ungali
nf
ect
i
ondi
agnosi
s:
(
CERTNTY1)
4.Sever
i
t
yofi
nf
ec
t
i
on:
(
SVRTY01)
I
NFECTI
ON I
I
5.Typeofi
nf
ect
i
on:
(
I
NFTYP02)
6.Or
gani
smI
I
:
(
ORGN02)
I
fot
herspeci
f
y
:
(
I
NFSPEC2)
7.Recor
dt
hel
ev
el
ofc
er
t
ai
nt
yoft
hef
ungali
nf
ect
i
ondi
agnosi
s:
(
CERTNTY2)
8.Sever
i
t
yofi
nf
ec
t
i
on:
(
SVRTY02)
I
NFECTI
ON I
I
I
9.Typeofi
nf
ect
i
on:
(
I
NFTYP03)
10.Or
gani
smI
I
I
:
(
ORGN03)
I
fot
herspeci
f
y
:
(
I
NFSPEC3)
11.Recor
dt
hel
ev
el
ofc
er
t
ai
nt
yoft
hef
ungali
nf
ect
i
ondi
agnosi
s:
(
CERTNTY3)
12.Sever
i
t
yofi
nf
ec
t
i
on:
(
SVRTY03)
13.Wasanagent
(
s
)admi
ni
st
er
edt
ot
r
eatt
hei
nf
ect
i
on(
s)
?(
TRTI
NF)
1-Yes
2-No
1-Yes
2-No
Pr
ovi
deagent
(
s)admi
ni
st
er
edf
ort
hi
si
nf
ect
i
ousper
i
od:
14.1stagent
:
(
AGENT1)
I
fot
herspeci
f
y
:
(
AGTSPEC1)
15.2ndagent
:
(
AGENT2)
I
fot
herspeci
f
y
:
(
AGTSPEC2)
d
16. r
3 agent
:
(
AGENT3)
I
fot
herspeci
f
y
:
(
AGTSPEC3)
17.Wer
eaddi
t
i
onal
agent
sadmi
ni
st
er
edf
ort
hi
si
nf
ec
t
i
ousper
i
od?(
ADDAGENT)
I
fyes,speci
f
yaddi
t
i
onal
agent
sadmi
ni
st
er
ed:
(
I
NFSPEC4)
Comment
s:
(
I
NFCOM)
Addi
t
i
ona
lSel
ect
i
onOpt
i
onsf
orI
NF
I
nf
ect
i
onSi
t
e(
I
NFSI
TE)(
keyf
i
el
d)
:
01-Bl
ood/
Buf
f
yCoat
02-Di
ss
emi
nat
ed-Gener
al
i
z
ed,I
sol
at
edat2orMor
eDi
s
t
i
nctSi
t
es
03-Br
ai
n
04-Spi
nalCor
d
05-Meni
ngesandCSF
06-Cent
r
alNer
vousSy
st
em Uns
pec
i
f
i
ed
07-Li
ps
08-Tongue,Or
alCav
i
t
y,andOr
oPhar
ynx
09-Esophagus
10-St
omac
h
11-Gal
l
bl
adderandBi
l
i
ar
yTr
ee(
NotHepat
i
t
i
s)
,Pancr
eas
12-Smal
lI
nt
es
t
i
ne
13-Lar
geI
nt
es
t
i
ne
14-Feces/
St
ool
15-Per
i
t
oneum
16-Li
ver
17-Gast
r
oi
nt
est
i
nalTr
actUnspeci
f
i
ed
18-UpperAi
r
wayandNas
ophar
ynx
19-Lar
y
nx
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on:1.
0;5.
00;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Labor
a
t
or
yAs
sessment
s
1.St
ar
tofAss
es
smentPer
i
od:
(
LA6APST)
(
mm/
dd/
yyy
y)
2.Tar
getAssess
mentDat
e:
(
LA6APEND)
(
mm/
dd/
yyy
y)
3.EndofAss
es
smentPer
i
od:
(
LA6APEND)
(
mm/
dd/
yyy
y)
4.Pat
i
ent
'
sbodywei
ght
:
(
LA6WGTKG)
(
x
xx.
x) k
g(
LA6WGTLB)
(
xxx
.
x) l
b
CBC
MostRec
entVal
ue
Dat
eofSampl
e
Dat
eofSampl
e
5. Hemat
ocr
i
t
(
LA6HCT)
(
xx
.
x
)%
(
LA6HCTDT)
(
mm/
dd/
yyy
y) (
LA6HCTDT)
(
mm/
dd/
y
yyy)
6. Hemogl
obi
n
(
LA6HGB)
(
xx
.
x) g/
dL
(
LA6HGBDT)
(
mm/
dd/
yyy
y) (
LA6HGBDT)
(
mm/
dd/
yy
yy)
7. WBC
(
LA6WBC)
(
x
xxxx
x) /
mc
L (
LA6WBCDT)
(
mm/
dd/
yy
yy) (
LA6WBCDT)
(
mm/
dd/
yyy
y)
8. Pl
at
el
etCount (
LA6PLAT)
(
xxx
xxx
)/
mcL (
LA6PLADT)
(
mm/
dd/
y
yyy
) (
LA6PLADT)
(
mm/
dd/
yyy
y)
9. Neut
r
ophi
l
s
(
LA6NEUT)
(
x
xxxx
)/
mcL
(
LA6NEUDT)
(
mm/
dd/
y
yyy) (
LA6NEUDT)
(
mm/
dd/
yyy
y)
10. Lymphoc
yt
es (
LA6LYMP)
(
xxx
xx) /
mc
L
(
LA6LYMDT)
(
mm/
dd/
y
yyy) (
LA6LYMDT)
(
mm/
dd/
yyy
y)
(
LA6EOSDT)
(
mm/
dd/
y
yyy) (
LA6EOSDT)
(
mm/
dd/
yyy
y)
11. Eosi
nophi
l
s
(
LA6EOS)
(
xx.
x) %
Chemi
st
r
yandLFT'
s
MostRecentVal
ue
12. Cr
eat
i
ni
ne
(
LA6CREAT)
mg/
dL
13. Tot
alBi
l
i
r
ubi
n
(
LA6BI
LI
)
mg/
dL
14. Al
k
al
i
ne
Phos
phat
ase
(
LA6ALKPH)
(
x
xxx
)I
U/
L
15. AST
(
LA6AST)
I
U/
L
16. ALT
(
LA6ALT)
I
U/
L
17. Chol
est
er
ol
(
LA6CHOL)
mg/
dL
18. Tr
i
gl
y
cer
i
des
(
LA6TRI
G)
mg/
dL
ULNForYourI
ns
t
i
t
ut
i
on
(
x
.
x)
Dat
eofSampl
e
Dat
eofSampl
e
(
LA6CREDT)
(
mm/
dd/
yy
yy)
(
LA6CREDT)
(
mm/
dd/
yyy
y)
(
LA6BI
LDT)
(
mm/
dd/
yy
yy)
(
LA6BI
LDT)
(
mm/
dd/
yyy
y)
(
LA6ALKUN)
I
U/
L
(
x
xx) (
LA6APDT)
(
mm/
dd/
yy
yy)
(
LA6APDT)
(
mm/
dd/
yyy
y)
(
x
xxx
) (
LA6ASTUN)
I
U/
L
(
xx
x) (
LA6ASTDT)
(
mm/
dd/
yy
yy)
(
LA6ASTDT)
(
mm/
dd/
yyy
y)
(
xx
x) (
LA6ALTDT)
(
mm/
dd/
yy
yy)
(
LA6ALTDT)
(
mm/
dd/
yyy
y)
(
xx
x)
(
LA6CHODT)
(
mm/
dd/
yy
yy)
(
LA6CHODT)
(
mm/
dd/
yyy
y)
(
xx
xx)
(
LA6TRI
DT)
(
mm/
dd/
yy
yy)
(
LA6TRI
DT)
(
mm/
dd/
yyy
y)
(
xx.
x)
(
xx
x)
(
LA6BI
LUN)
(
xx.
x) mg/
dL
(
LA6ALTUN)
I
U/
L
Pul
monar
yFunct
i
onTest
s
MostRecentVal
ue
19. FEV1 (
LA6FEV)
(
xxx) % ofpr
edi
c
t
edval
ue
Dat
eofSampl
e
(
LA6FEVDT)
(
mm/
dd/
yyy
y) (
LA6FEVDT)
(
mm/
dd/
y
yyy
)
20. FVC1 (
LA6FVC)
21. DLCO (
LA6DLCO)
Comment
s:
(
LA6CMNTS)
(
xx
x) % ofpr
edi
ct
edval
ue
(
LA6FVCDT)
(
mm/
dd/
y
yyy
) (
LA6FVCDT)
(
mm/
dd/
yy
yy)
(
xxx
) % ofpr
edi
ct
edv
al
ue (
LA6DLCDT)
(
mm/
dd/
y
yyy
) (
LA6DLCDT)
(
mm/
dd/
yy
yy)
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Medi
ca
t
i
onFor
m -0801(
MD6
)
WebVer
si
on:1.
0;4.
03;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
1.Assess
mentst
ar
tdat
e:
(
MD6STDT)
(
mm/
dd/
y
yyy
)
2.Tar
getasses
smentdat
e:
(
MD6ENDDT)
(
mm/
dd/
y
yyy
)
3.Assess
mentenddat
e:
(
MD6ENDDT)
(
mm/
dd/
y
yyy
)
4.Hast
hepat
i
entev
err
ec
ei
v
edast
er
oi
ddoseof>2mg/
kg/
daydur
i
ngt
heass
essment
per
i
od?(
MD6STRD)
1-Yes
2-No
I
fYes,aSecondar
yTher
apyFor
m mustbes
ubmi
t
t
ed.
5.I
ndi
cat
edat
epat
i
entr
ec
ei
v
edst
er
oi
ddos
eof>2mg/
kg/
day.
(
MD6STRDT)
(
mm/
dd/
y
yyy
)
6.STUDYTHERAPYt
hepat
i
enti
sr
ec
ei
v
i
ng:
(
MD6THPRC)
STUDYTHERAPY
St
er
oi
d
CNI
(
MD6CNI
)
(
MD6MTPD)
Cur
r
ent
l
yRecei
vi
ng
Si
r
ol
i
mus
(
MD6PRDCT)
(
MD6CNI
CT)
(
MD6SI
RCT)
DoseSchedul
e
(
MD6PRDHO)
Dose1
(
MD6PR1D)
(
xxx
.
x)
Dose2
(
MD6PR2D)
(
xxx
.
x)
DoseUni
t
s
(
MD6DSUNT)
Dat
eWi
t
hhel
d
(
MD6PRDDT)
(
mm/
dd/
yy
yy)
(
MD6CNI
DT)
(
mm/
dd/
y
yyy)
(
MD6SI
RDT)
(
mm/
dd/
y
yyy
)
Dat
eWi
t
hhel
d
(
MD6PRDDT)
(
mm/
dd/
yy
yy)
(
MD6CNI
DT)
(
mm/
dd/
y
yyy)
(
MD6SI
RDT)
(
mm/
dd/
y
yyy
)
Dat
eDi
scont
i
nued
(
MD6PRWDT)
(
mm/
dd/
yyy
y)
(
MD6CNWDT)
(
mm/
dd/
yy
yy)
(
MD6SRWDT)
(
mm/
dd/
yy
yy
Dat
eDi
scont
i
nued
(
MD6PRWDT)
(
mm/
dd/
yyy
y)
(
MD6CNWDT)
(
mm/
dd/
yy
yy)
(
MD6SRWDT)
(
mm/
dd/
yy
yy
Reason
(
MD6PRDRD)
Wi
t
hhel
d/
Di
scont
i
nued
(
MD6CNI
RD)
(
MD6SI
RRD)
I
fphysi
ci
andeci
si
on
orot
her
,speci
f
y
(
MD6OT1SP)
(
MD6OT2SP)
7.Wer
eCy
cl
ospor
i
neandTacr
ol
i
musi
nt
er
changedt
hi
sassess
mentper
i
od?(
MD6CNI
XG)
(
MD6OT3SP)
1-Yes
2-No
1-Yes
2-No
8.I
ndi
cat
er
easonf
ors
wi
t
c
hbet
weenCyc
l
os
por
i
neandTac
r
ol
i
mus:
(
MD6CYTAS)
9.I
fphy
si
ci
andeci
si
onorot
her
,speci
f
y
:
(
MD6CNI
SW)
10.Hast
hepat
i
entr
ec
ei
v
edanyoft
hef
ol
l
owi
ngagent
ssi
ncecGVHDdi
agnosi
s?
(
MD6AGTSD)
I
fYes,i
ndi
c
at
ewhi
chagent
swer
er
ecei
vedandt
hest
ar
tandst
opdat
es(
whenappl
i
cabl
e)
.
AgentRec
ei
v
ed
11. ECP
St
ar
tDat
e
St
opDat
e
(
MD6ECPDT)
(
mm/
dd/
y
yyy
) (
MD6ECSDT)
(
mm/
dd/
yyy
y)
(
MD6CYCDT)
(
mm/
dd/
yyy
y) (
MD6CYSDT)
(
mm/
dd/
yyy
y)
(
MD6TACDT)
(
mm/
dd/
yyy
y) (
MD6TASDT)
(
mm/
dd/
yyy
y)
(
MD6ECPSD)
12. Cyc
l
os
por
i
ne
(
MD6CYCSD)
13. Tac
r
ol
i
mus
(
MD6TACSD)
14. MMF
(
MD6MMFDT)
(
mm/
dd/
yy
yy) (
MD6MMSDT)
(
mm/
dd/
yy
yy)
(
MD6MMFSD)
15. Az
at
hi
opr
i
ne
(
MD6AZADT)
(
mm/
dd/
y
yyy
) (
MD6AZSDT)
(
mm/
dd/
yyy
y)
(
MD6AZASD)
16. Ri
t
ux
i
mab
(
MD6RI
TDT)
(
mm/
dd/
y
yyy
)
(
MD6RI
SDT)
(
mm/
dd/
y
yyy)
(
MD6I
NFDT)
(
mm/
dd/
y
yyy
)
(
MD6I
NSDT)
(
mm/
dd/
y
yyy)
(
MD6RI
TSD)
17. I
nf
l
i
x
i
mab
(
MD6I
NFSD)
18. Thal
i
domi
de
(
MD6THADT)
(
mm/
dd/
yyy
y) (
MD6THSDT)
(
mm/
dd/
yy
yy)
(
MD6ATGDT)
(
mm/
dd/
y
yyy
) (
MD6ATSDT)
(
mm/
dd/
yyy
y)
(
MD6PTSDT)
(
mm/
dd/
y
yyy
) (
MD6PTDT)
(
MD6THASD)
19. ATG
(
MD6ATGSD)
20. Pent
os
t
at
i
n
(
MD6PTSSD)
(
mm/
dd/
yy
yy)
21. Et
aner
c
ept
(
MD6ETNDT)
(
mm/
dd/
yyy
y) (
MD6ENSDT)
(
mm/
dd/
yyy
y)
(
MD6MTXDT)
(
mm/
dd/
y
yyy) (
MD6MXSDT)
(
mm/
dd/
yy
yy)
(
MD6OTHDT)
(
mm/
dd/
yyy
y) (
MD6OTSDT)
(
mm/
dd/
yyy
y)
(
MD6ETNSD)
22. Met
hot
r
ex
at
e
(
MD6MTXSD)
23. Ot
her
(
MD6OTHSD)
24.I
fot
heragent
,s
peci
f
y:
(
MD6OSDSP)
Comment
s:
(
MD6COMM)
Addi
t
i
ona
lSel
ect
i
onOpt
i
onsf
orMD6
Pr
edDi
sc/
Wi
t
hRsn
6-Ot
her
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Speci
menAcqui
si
t
i
onFor
m -0801(
SA3)
WebVer
si
on:1.
0;1.
01;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
Besur
et
oent
ert
hecol
l
ect
i
onandshi
pmentofspeci
mensi
nt
oGl
obal
Tr
aceassoonaspossi
bl
e.
1.Wer
ebl
oodsampl
esf
orBAFFl
evel
sbyELI
SAc
ol
l
ect
ed?(
BAFFLVLS)
I
fyes,r
ecor
dt
hedat
et
hebl
oods
ampl
eswer
ecol
l
ec
t
ed:
(
BAFFDT)
2.Wer
ebl
oodsampl
esf
orRegul
at
or
yTcel
landBcel
lI
mmunophenot
y
pi
ng
c
ol
l
ec
t
ed?(
I
MMUNOPH)
1-Yes
1-Yes
I
fyes,r
ecor
dt
hedat
et
hebl
oods
ampl
eswer
ecol
l
ec
t
ed:
(
I
MMUNODT)
3.Wer
ebucc
al
swabscol
l
ec
t
ed?(
BUCCSWAB)
I
fyes,r
ecor
dt
hedat
et
hebuccals
wabswer
ec
ol
l
ect
ed:
(
BUCSWBDT)
4.Wer
ebl
oodsampl
escol
l
ect
edf
orf
ut
ur
er
esear
ch?(
SA3PLSMA)
I
fyes,r
ecor
dt
hedat
et
hebl
oods
ampl
eswer
ecol
l
ec
t
ed:
(
SA3PLSDT)
Comment
s:
(
SA3CMMNT)
2-No
(
mm/
dd/
yy
yy)
2-No
(
mm/
dd/
yy
yy)
1-Yes
2-No
(
mm/
dd/
yy
yy)
1-Yes
2-No
(
mm/
dd/
yy
yy)
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Sec
ondar
yTher
apyFor
m(
SCT)
WebVer
si
on:1.
0;2.
00;101615
Secondar
yTher
apyDat
e(
SCTDT)
:
Secondar
yi
mmunosuppr
ess
i
vesy
st
emi
ct
her
apyi
nc
l
udesanyi
nt
er
vent
i
oni
nt
endedt
ocont
r
olc
hr
oni
cGVHD t
hr
oughani
mmunosuppr
ess
i
veef
f
ec
tf
r
om or
al
orpar
ent
er
al
admi
ni
s
t
r
at
i
onofanysy
st
emi
cmedi
cat
i
onnotor
i
gi
nal
l
ygi
v
enundert
heauspi
c
esoft
hi
spr
ot
ocolf
ort
r
eat
mentofchr
oni
cGVHD.SeeSect
i
on3.
3.
2oft
hepr
ot
oc
ol
f
or
ex
ampl
es.
Rec
or
dsecondar
ysys
t
emi
ci
mmunos
uppr
essi
vet
her
apyagent
sadmi
ni
st
er
ed:
1.1s
tagent
:
(
SCTAGNT1)
Speci
f
yot
her1stagent
:
(
SCTOT1SP)
2.St
ar
tdat
e:
(
SCTAT1DT)
(
mm/
dd/
yyy
y)
3.2ndagent
:
(
SCTAGNT2)
Speci
f
yot
her2ndagent
:
(
SCTOT2SP)
4.St
ar
tdat
e:
(
SCTAT2DT)
(
mm/
dd/
yyy
y)
5.3r
dagent
:
(
SCTAGNT3)
Speci
f
yot
her3r
dagent
:
(
SCTOT3SP)
6.St
ar
tdat
e:
(
SCTAT3DT)
(
mm/
dd/
yyy
y)
7.Wassec
ondar
yt
her
apygi
venduet
opr
ogr
essi
onofcGVHD?(
SCTCGVHD)
1-Yes
I
ndi
cat
ewhi
chor
gansy
st
em(
s)hav
epr
ogr
essedt
hatl
eadt
ot
hest
ar
tofsecondar
yt
her
apy.
8. Ski
n
(
SCTSKI
N)
9. J
oi
nt
s
(
SCTJNT)
1-Yes
2-No
10. Fas
ci
a
(
SCTFSC)
1-Yes
2-No
11. Lung
(
SCTLUNG)
1-Yes
1-Yes
12. Ur
ogeni
t
al (
SCTUGNTL)
1-Yes
13. Li
ver
(
SCTLI
VER)
14. Mout
h
(
SCTMOUTH)
15. Esophagus (
SCTESPH)
16. LowerGI
(
SCTLGI
)
1-Yes
1-Yes
1-Yes
1-Yes
2-No
2-No
2-No
2-No
2-No
2-No
2-No
2-No
17. Ot
her
(
SCTOOT)
I
fOt
her
,spec
i
f
y:
(
SCTOOSP)
Comment
s:
(
SCTCOMM)
1-Yes
2-No
Addi
t
i
ona
lSel
ect
i
onOpt
i
onsf
orSCT
1stagent
:
06-Ri
t
ux
i
mab
07-I
nf
l
i
x
i
mab
08-Thal
i
domi
de
09-Ant
i
t
hymoc
yt
eGl
obul
i
n
10-Pent
ost
at
i
n
11-Et
aner
c
ept
12-Met
hot
r
ex
at
e
99-Ot
her
Bl
ooda
ndMar
r
ow Tr
anspl
antCl
i
ni
cal
Tr
i
al
sNet
wor
k
Toxi
ci
t
yFor
m -0
801(
T16)
WebVer
si
on:1.
0;5.
01;101615
Segment(
PROTSEG)
:
Vi
si
tNumber(
VI
SNO)
:
1.Rec
or
ddat
eofeval
uat
i
on:
(
T16X7EVL)
(
mm/
dd/
yy
yy)
Recor
dt
hehi
ghestgr
adeoft
oxi
ci
t
ydi
agnosedsi
ncet
hepr
evi
ouseval
uat
i
on.I
ft
hi
si
st
hef
i
r
steval
uat
i
on,r
ecor
dt
hehi
ghestt
oxi
ci
t
ydi
agnosedsi
nce
enr
ol
l
mentont
heBMT0801st
udy.Thet
oxi
ci
t
ygr
adesar
ebasedont
heNCICTCAEVer
si
on3.
0.
RenalToxi
ci
t
y
2.Di
dt
hepat
i
entex
per
i
encer
enalf
ai
l
ur
esever
eenought
o
war
r
antdi
al
ysi
s
?(
T16RENAL)
3.Di
dt
hepat
i
entr
ecei
vedi
al
ysi
s?(
T16DI
ALS)
4.Cr
eat
i
ni
ne:
(
T16CREAT)
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
Hemor
r
hagi
cToxi
ci
t
y
5.Hemor
r
hage:
(
T16HEMRG)
Car
di
ovascul
arToxi
ci
t
y
6.Hy
per
t
ens
i
on:
(
T16HYPER)
Neur
ol
ogi
cToxi
ci
t
y
7.Di
dt
hepat
i
entex
per
i
enceanysei
zur
esdur
i
ngt
hi
sassess
ment
per
i
od?(
T16SEI
ZR)
8.Recor
ds
ei
z
ur
et
ox
i
ci
t
ygr
ade:
(
T16SZGRD)
Muscul
oskel
et
alandConnect
i
veTi
ssueToxi
ci
t
y
9.Avascul
arnecr
osi
s:
(
T16NECRO)
10.Ost
eopor
osi
s:
(
T16OSTEO)
Endocr
i
neToxi
ci
t
y
11.Gl
ucosei
nt
ol
er
anc
e/
Di
abet
es:
(
T16DI
AB)
Coagul
at
i
onToxi
ci
t
y
12.HUS/
TTP/
t
hr
ombot
i
cmi
c
r
oangi
opat
hy:
(
T16DI
C)
13.Thr
ombocyt
openi
a:
(
T16THROM)
14.Anemi
a:
(
T16ANEM)
Der
mat
ol
ogy/
Ski
nToxi
ci
t
y
15.Phot
osensi
t
i
v
i
t
y:
(
T16PHOTO)
Vascul
arToxi
ci
t
y
16.Ser
i
ousCat
het
erAssoci
at
edCompl
i
cat
i
ons(
SCAC)
:
(
T16SCAC)
Pul
monar
yToxi
ci
t
y
17.Pneumoni
t
i
s(
NI
P)
:
(
T16NI
P)
18.Hy
pox
i
a(
f
ormor
et
han24hour
s)
:
(
T16HYPXI
)
Chemi
st
r
y
Onl
yt
hemos
tabnor
mali
nt
er
i
mv
al
ueshoul
dber
ecor
ded.
19.Chol
est
er
ol
:
(
T16CHOLE)
20.Tr
i
gl
ycer
i
des
:
(
T16TRI
GL)
21.Hy
poc
al
c
emi
a:
(
T16HCAL)
Hepat
i
cToxi
ci
t
y
22.ALT:
(
T16ALT)
23.AST:
(
T16AST)
24.Bi
l
i
r
ubi
n:
(
T16BI
LI
R)
25.Al
k
al
i
nePhosphat
ase:
(
T16ALKPH)
I
ndi
cat
eal
lc
l
i
ni
cals
i
gns/
s
ympt
omsofabnor
mall
i
v
erf
unct
i
oni
ngpr
es
entdur
i
ngt
hi
sasses
smentper
i
od:
26.J
aundi
ce:
(
T16JANDC)
1-Yes
2-No
27.Hepat
omegal
y:
(
T16HPTMG)
1-Yes
2-No
1-Yes
2-No
1-Yes
2-No
28.Ri
ghtupperquadr
antpai
n:
(
T16QUADP)
29.Wei
ghtgai
n(
>5%)f
r
om basel
i
ne:
(
T16WGHTG)
30.I
ndi
cat
et
heet
i
ol
ogyoft
heabnor
mall
i
verf
unct
i
on:
Et
i
ol
ogy
Bi
opsyResul
t
s
Doppl
erUl
t
r
asoundResul
t
s
VOD:
(
T16VODET)
(
T16VODBI
)
(
T16VODDP)
GVHD:
(
T16GVHET)
(
T16GVHBI
)
(
T16GVHDP)
I
nf
ect
i
on:
(
T16I
NFET)
(
T16I
NFBI
)
(
T16I
NFDP)
Ot
her
:
(
T16OTHET)
(
T16OTHBI
)
Unknown:
(
T16UNKET)
Spec
i
f
yot
heret
i
ol
ogy:
(
T162SPEC)
Comment
s:
(
T16COMM)
(
T16OTHDP)
Addi
t
i
ona
lSel
ect
i
onOpt
i
onsf
orT1
6
Hyper
t
ensi
on:
5-Deat
h