Patient Information Form – CAR-T Cell Therapy Trial

If you experience any issues with the form, please feel free to contact Manina Etter directly at manina.etter@unibas.ch

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Name *

First

Last

Date of birth *Day12345678910111213141516171819202122232425262728293031

Date of birth *MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Date of birth *Year19101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025

Gender *— Select Choice —MaleFemaleOtherPrefer not to say

Nationality *

Address *

Phone number

Email *

Date of first glioma diagnosis *Day12345678910111213141516171819202122232425262728293031

Date of first glioma diagnosis *MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Date of first glioma diagnosis *Year19101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025

How was your tumor initially diagnosed?

• Surgery/biopsy
• Imaging (MRI/CT)
• Other

If other, please define

Treatments you have received so far

• Surgery
• Radiotherapy
• Chemotherapy
• Other treatments

(check all that apply)

Where have you been treated so far?

Has your tumor been tested for the EGFRvIII mutation?

• Yes, mutation is present
• Yes, mutation is absent
• Not yet tested
• I don’t know

Are medications: the

Have you experienced a recurrence of glioblastoma after initial therapy?

• Yes
• No

If yes, when was recurrence diagnosed?

Do you have any other serious medical conditions?

• Yes
• No

If yes, please specify:

Current medications:

Are you currently enrolled in another clinical trial?

• Yes
• No

If yes, please specify

Message / Comments

Consent *

• I confirm that the above information is accurate and I consent to be contacted by the study team.

Submit