Phase 1 Data Collection: EHR Form

​Please complete a Chart Review and a Treatment Sequencing Form for five individual de-identified patients with R/R CLL/SLL. Select patients who are representative of your typical clinic population.

You will complete a new form for each of your five patients.

Your Name

Chart Review:

For any information not available, note it as “not documented” or “unknown.” For each patient, provide the following baseline information:
Current age or age at the time of last follow-up, as appropriate
If ECOG is not available, provide clinical description
If available, note severity or whether the condition is controlled

Treatment Line

Fill out the information based on the patient’s actual treatment history.
Enter a number
NOTE: If patient is still on treatment, note as "ongoing"
NOTE: If no testing was done, write "not performed"
Why was this therapy selected (check all that apply)?
*Example of patient preference: Patient asking to receive oral medications only +Examples of HCP preference: Preference for agents/regimens familiar to the HCPs; care team proficient in prophylaxis, and monitoring/management of adverse events associated with selected agent/regimens

Click on "Add a Treatment Line" for each additional treatment line you gave to the patient.  Treatment Line #5 would be inclusive of lines 5+.

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