CLL Sample Questionnaire

Below is the list of questions that you will be asked when completing the
CLL Tracker questionnaire. We recommend that you familiarise yourself with
the data required prior to completing the questionnaire.

When completing the questionnaire you do have the option of completing as
much as you can complete and then save. You can then returned to the saved
data at a later date.

DEMOGRAPHICS
Your Age
Your Sex

DIAGNOSIS AND STAGING AT DIAGNOSIS
Date of Diagnosis
Your Staging at Diagnosis: (Rai)
Your Staging at Diagnosis: (Binet)
How Did You Find Out You Had CLL
Your Symptoms at Diagnosis
Do You Have Familial CLL
Are You Watch and Wait (Received no treatment)
If You Have Received Treatment, Are You Currently in Remission

PROGNOSTIC MARKERS AT DIAGNOSIS
CD38
ZAP70
IgVH

FISH MARKERS AT DIAGNOSIS - Fluorescence In Situ Hybridization
17p13 Deletion (TP53 gene)
13p14 Deletion (ATM gene)
11q23 Deletion
6q21 Deletion
12q Trisomy

YOUR BLOOD RESULTS
White Blood Cell Count (WBC) at diagnosis
Prior to treatment did your wbc double
If 'Yes' Above How Long Did The WBC Take to Double
HB (Hemoglobin) Blood Cell Count at Diagnosis
Platelet Blood Cell Count at Diagnosis

TREATMENT*
Date of Start of Treatment
Date of Finish of Treatment
Name of Treatment
Reason for Treatment
No of Rounds Completed for Treatment
Complications During Treatment

*Note the above treatment questions are repeated for subsequent treatments
received.

FINALLY
Any Additional Comments