Breast Cancer (NCT00024102) Header Patient characteristics Other cancers or leukemia Yes
No
How much does it interfere with your activities: Other cancers or leukemia (b.) Arthritis, rheumatism, or other connective tissue disorders (b.) Yes
No
How much does it interfere with your activities: Arthritis, rheumatism, or other connective tissue disorders (c.) Glaucoma (c.) Yes
No
How much does it interfere with your activities: Glaucoma (d.) Emphysema or Chronic Bronchitis (d.) Yes
No
How much does it interfere with your activities: Emphysema or Chronic Bronchitis (e.) High Blood Pressure (e.) Yes
No
How much does it interfere with your activities: High Blood Pressure (f.) Heart disease (f.) Yes
No
How much does it interfere with your activities: Heart disease (g.) Circulation trouble in arms or legs (g.) Yes
No
How much does it interfere with your activities: Circulation trouble in arms or legs (h.) Diabetes (h.) Yes
No
How much does it interfere with your activities: Diabetes (i.) Stomach or intestinal disorders (i.) Yes
No
How much does it interfere with your activities: Stomach or intestinal disorders (j.) Osteoporosis (j.) Yes
No
How much does it interfere with your activities: Osteoporosis (k.) Chronic Liver or Kidney Disease (k.) Yes
No
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.) Stroke (l.) Yes
No
How much does it interfere with your activities: Stroke (m.) Depression (m.) Yes
No
How much does it interfere with your activities: Depression How is your eyesight (with glasses or contacts)? (mark one with an X) If fair, poor or totally blind, how much does this interfere with your activities? (mark one with an X) How is your hearing (with a hearing aid, if needed)? (mark one with an X) If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X) Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health? how much does this interfere with your activities? (mark one with an X) About how many times have you seen a doctor during the past 3 months, other than as an inpatient in a hospital? (6.) During the past 3 months, how many days were you so sick that you were unable to carry out your usual activities - such as going to work or working around the house? (mark one with an X) How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X) Counseling Medication Medicine to treat nausea and/or vomiting Yes
No
Medicine to treat diarrhea Yes
No
Medicine to reduce feeling very tired [fatigue] Yes
No
Medicine to reduce swelling in hands or feet Yes
No
Medicine or cream to treat mouth sores Yes
No
Pain medicine for hands or feet Yes
No
Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet Yes
No
Other, specify Yes
No
Arthritis medicine (If Taken, How Often?) Yes
No
If Taken, How Often: Arthritis medicine (b.) Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment) Yes
No
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment) Over-the counter pain killers (c.) Yes
No
If Taken, How Often: Over-the counter pain killers (other than for arthritis) High blood pressure medicine (d.) Yes
No
If Taken, How Often: High blood pressure medicine (e.) Pills to make you lose water or salt (water pills or diuretics and not due to side effects from cancer treatment) Yes
No
If Taken, How Often: Pills to make you lose water or salt (f.) Digoxin pills for the heart (Lanoxin) Yes
No
If Taken, How Often: Digoxin pills for the heart (Lanoxin) Nitroglycerin for chest pain (tablets or patches) Yes
No
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches) Blood thinner medicine (anticoagulants) Yes
No
If Taken, How Often: Blood thinner medicine (anticoagulants) Medicine to improve circulation (i.) Yes
No
If Taken, How Often: Medicine to improve circulation (j.) Insulin injections for diabetes (j.) Yes
No
If Taken, How Often: Insulin injections for diabetes (k.) Pills for diabetes (k.) Yes
No
If Taken, How Often: Pills for diabetes (l.) Ulcer medicine (l.) Yes
No
If Taken, How Often: Ulcer medicine (m.) Asthma medicines (m.) Yes
No
If Taken, How Often: Asthma medicines (n.) Seizure medicines (like Dilantin) Yes
No
If Taken, How Often: Seizure medicines (like Dilantin) Thyroid pills (If Taken, How Often?) Yes
No
If Taken, How Often: Thyroid pills (p.) Cortisone pills or injections (p.) Yes
No
If Taken, How Often: Cortisone pills or injections (q.) Antibiotics (q.) Yes
No
If Taken, How Often: Antibiotics (r.) Tranquilizers or medicine for your nerves (r.) Yes
No
If Taken, How Often: Tranquilizers or medicine for your nerves (s.) Prescription sleeping pills (s.) Yes
No
If Taken, How Often: Prescription sleeping pills (t.) Over-the-counter pills to help you sleep (t.) Yes
No
If Taken, How Often: Over-the-counter pills to help you sleep (u.) Hormones (male or female) Yes
No
If Taken, How Often: Hormones (v.) Allergy medicines (v.) Yes
No
If Taken, How Often: Allergy medicines (w.) Laxatives (w.) Yes
No
If Taken, How Often: Laxatives (x.) Eye drops for glaucoma (x.) Yes
No
If Taken, How Often: Eye drops for glaucoma (y.) Calcium tablets (y.) Yes
No
If Taken, How Often: Calcium tablets (z.) Vitamins and/or minerals (other than calcium) Yes
No
If Taken, How Often: Vitamins and/or minerals (other than calcium) Herbal medicines (aa.) Yes
No
If Taken, How Often: Herbal medicines (12.) Have you taken any other medicines in the past month? Yes
No
If Taken, How Often?