1. Annual Status Report

* NWTSID

* Last 4 digits of Social Security # (optional)

* Participant's name

* Participant's Date of Birth

* Date of last contact

Please provide all known information

* Weight

* Unit

* Height

* Unit

If this participant has had any of the following illnesses or conditions resulting in hospitalization, surgery or other medical treatment since last report, or if previously unreported, please use the space below to report each event.

If reporting relapse of Wilms tumor, please mail or fax detailed flowsheets in addition to this form.
  • Heart disease or congestive heart failure
  • Cancer (after first Wilms tumor)
  • Renal failure, kidney problems or transplant
  • Other serious illness or medical conditions

* Events to report

* First Event

* First Event Date

* Description/Outcome/Treatment of First Event

* Second Event

* Second Event Date

* Description/Outcome/Treatment of Second Event

* Third Event

* Third Event Date

* Description/Outcome/Treatment of Third Event

* Additional Comments

Has this participant experienced any significant life events (such as marriage, pregnancy or parenthood) since last report?

If yes, or if previously unreported, please use the space below to report each event. For pregnancies, include date pregnancy ended, duration of pregnancy and outcome.

* Events to report

* First Event

* First Event Date

* Description/Outcome of First Event

* Second Event

* Second Event Date

* Description/Outcome of Second Event

* Third Event

* Third Event Date

* Description/Outcome of Third Event

* Additional Comments

* Name of person completing the form

* Survey Date

Thank you!

Your participation is an important contribution to our research

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