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10.2 APPENDIX B: GLOBAL SCORING OF CHRONIC GVHD107 SCORE 0 SCORE 1 SCORE 2 SCORE 3 PERFORMANCE SCORE: (Appendix H) KPS ECOG LPS

SKIN Clinical features:

% BSA involved

<NO

OR OROR

MOUTH

with

with

EYES

OR

WITHOUT

OROR

GI TRACT

OR

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SCORE 0 SCORE 1 SCORE 2 SCORE 3 LIVER

LUNGS*

FEV1 DLCO

OR

OR

OR

OR

JOINTS AND FASCIA

AND

OR

AND

WITH AND

GENITAL TRACT AND

AND

WITH

AND

*"AP#may#be#elevated#in#growing#children,#and#not#reflective#of#liver#dysfunction"

Other"indicators,"clinical"manifestations"or"complications"related"to"cGVHD"(check"all"that"apply"and"assign"a"score"to"its"severity"based"on"its"functional"

impact"(none"–"0,"mild"–"1,"moderate"–"2,"severe"–"3):#___Esophageal#stricture#or#web# ___Pericardial#Effusion# # ___Pleural#Effusion(s)#

___Ascites#(serositis)# ___Nephrotic#syndrome# # ___Peripheral#Neuropathy#

___Myasthenia#Gravis# ___Cardiomyopathy# # ___Eosinophilia#>#500μl#___Polymyositis## # ___Cardiac#conduction#defects# ___Coronary#artery#involvement#

___Platelets#<100,000/μl## ___Progressive#onset#

___OTHERS:"

##

#

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http://www.asco.org/quality -guidelines/informed-consent-chemotherapy-administration 9/2/07

[Name of Physician Practice]

Consent to Chemotherapy

(check all that apply; additional space provided for physician comments)

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© American Society of Clinical Oncology 2008. All rights reservedInformed consent is an ongoing communication process. Consent forms, including this template, are in no way intended to replace or

limit, in whole or in part, the thorough exchange of information between physicians and patients, and should not be used in this manner. Though the consent template reflects basic informed consent requirements, no single consent form could be appropriate for

all patients. It is the responsibility of the treating physician or other health care provider to tailor the consent process to meet individual patient’s needs. Because the consent form can include confidential information about a patient’s medical record and

treatment regimen, it should be used or disclosed only in accordance with federal and state privacy laws. Laws governing informed consent vary from state to state and may change over time. Before using the template, health care providers are advised to consult legal counsel to determine whether all required elements of informed consent are addressed. Use of this consent template is entirely

voluntary and does not imply ASCO’s endorsement of any physician practice, treatment regimen, or product. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related any use of this Template, any changes made to

this Template by the user, or any errors or omissions.

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