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					A Randomized Multicentre Study Comparing G-CSF Mobilized Peripheral Blood and G-CSF Stimulated Bone Marrow in
                  Patients Undergoing Matched Sibling Transplant for Hematologic Malignancies


             Recipient’s Initials: |__|__|__|                     Recipient Study#:        |__|__|__|__|

                           Circle one:             Month 1        Month 2        Month 3

      Month 6        Month 9         Month 12        Month 15        Month 18      Month 21       Month 24

                                HEALTH CARE QUESTIONNAIRE
   (A) Health Care Visits
   Please read about the following types of health care visits before completing this form:
   1) Outpatient clinic visit: Visits which occur in a clinic where patients can be assessed by a
      doctor, a specialist, or other health care professional AND/OR have a procedure such as blood
      work, dressing change, IV medication, blood transfusion, biopsy, etc. Usually the doctors and
      health care professionals have specialized training in the field of cancer and/or hematopoietic
      stem cell transplant. An outpatient visit may involve anything from a brief assessment to
      several procedures and/or several assessments.
   2) Specialist visit: A visit to a doctor with specialized training (hematologist, cardiologist,
      surgeon, psychiatrist, dermatologist, etc) at a location other than an outpatient clinic.
   3) Other health care visit: A visit to any of the following health care professionals: family doctor,
      nurse practitioner, pharmacist, psychologist, physiotherapist, naturopath, massage therapist,
      chiropractor or dietician at a location other than an outpatient clinic.
   4) Emergency Room visit: A visit to the Emergency Department of a hospital.

   Time Period Covered by this Form: (Study Coordinator to enter start and end dates)

   Start Date: |__|__| |__|__|__| |__|__|__|__|               End Date: |__|__| |__|__|__| |__|__|__|__|
                    DD        MMM           YYYY                            DD       MMM           YYYY



    In this time period:
   1. How many times have you had an outpatient clinic visit?                                             ______

   2. How many times have you had a specialist visit?                                                     ______

   3. How many times have you had any other health care visit?                                            ______

   4. How many times have you had an Emergency Room visit?                                                ______
       (Not admitted overnight – If admitted count as a “hospitalization”.)

   (B) Hospitalizations
   1. How many times have you been admitted to a hospital overnight?     ______
_______________________________________________________________________________

   Date of Completion: |__|__| |__|__|__| |__|__|__|__|
                               DD        MMM           YYYY

   Completed by (check all that apply):
    Subject (hard copy)            Study coordinator (interview)       Study coordinator (source documents)

   Version 27-May-2009                      Page 1 of 2
          A Randomized Multicentre Study Comparing G-CSF Mobilized Peripheral Blood and G-CSF Stimulated Bone
                  Marrow in Patients Undergoing Matched Sibling Transplant for Hematologic Malignancies


                  Recipient’s Initials: |__|__|__|                     Recipient Study#:           |__|__|__|__|

                              Circle one:            Month 1          Month 2            Month 3

           Month 6        Month 9        Month 12       Month 15         Month 18          Month 21       Month 24

       (C) Medications
  Please list all medications that you took in the last week:
 Name of Medication         Dose            Route                                           Frequency
                                                   by mouth                     once per day            twice per day
                                                                                three times per day     four times per day
e.g.   gancyclovir                  400mg          by intravenous
                                                   other                        other:   3 times per week
                                                   by mouth                     once per day          twice per day
                                                   by intravenous               three times per day   four times per day
                                                   other: ______________        other: _______________________________

                                                   by mouth                     once per day          twice per day
                                                   by intravenous               three times per day   four times per day
                                                   other: ______________        other: _______________________________

                                                   by mouth                     once per day          twice per day
                                                   by intravenous               three times per day   four times per day
                                                   other: ______________        other: _______________________________

                                                   by mouth                     once per day          twice per day
                                                   by intravenous               three times per day   four times per day
                                                   other: ______________        other: _______________________________

                                                   by mouth                     once per day          twice per day
                                                   by intravenous               three times per day   four times per day
                                                   other: ______________        other: _______________________________

                                                   by mouth                     once per day          twice per day
                                                   by intravenous               three times per day   four times per day
                                                   other: ______________        other: _______________________________

                                                   by mouth                     once per day          twice per day
                                                   by intravenous               three times per day   four times per day
                                                   other: ______________        other: _______________________________

                                                   by mouth                     once per day          twice per day
                                                   by intravenous               three times per day   four times per day
                                                   other: ______________        other: _______________________________

                                                   by mouth                     once per day          twice per day
                                                   by intravenous               three times per day   four times per day
                                                   other: ______________        other: _______________________________

                                                   by mouth                     once per day          twice per day
                                                   by intravenous               three times per day   four times per day
                                                   other: ______________        other: _______________________________


  Date of Completion: |__|__| |__|__|__| |__|__|__|__|
                              DD        MMM          YYYY



  Completed by (Check all that apply):
  Subject (hard copy)       Study coordinator (interview)         Study coordinator (source documents)


  Version 27-May-2009                              Page 2 of 2

				
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