Description:

Quality of Life Questionnaire Anastrozole or Tamoxifen in Treating Postmenopausal Women With Ductal Carcinoma in Situ Who Are Undergoing Lumpectomy and Radiation Therapy NCT00053898 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A0E240A0-FD2A-46A0-E034-080020C9C0E0

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A0E240A0-FD2A-46A0-E034-080020C9C0E0

  1. 8/26/12 8/26/12 -
  2. 8/7/14 8/7/14 - Martin Dugas
  3. 3/21/15 3/21/15 - Martin Dugas
  4. 4/10/21 4/10/21 -
  5. 9/20/21 9/20/21 -
Copyright Holder:
folgt
Uploaded on:

September 20, 2021

DOI:
To request one please log in.
License :
Creative Commons BY 4.0
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Breast Cancer (NCT00053898)

NSABP Protocol B-35 [At bottom ] Record the first three letters of patient's last name and study ID on each of the remaining pages before giving the questionnaire to the patient.

Header
Are data amended? (If yes, circle amended items in red.)
Time Point for this Questionnaire (Check One)
This form is being filled out
Symptom frequency
I was bothered by things that don't usually bother me.
I had trouble keeping my mind on what I was doing.
I felt depressed
I felt that everything I did was an effort.
I felt hopeful about the future.
I felt fearful.
My sleep was restless.
I was happy.
I felt lonely.
I could not get ´going´
Everyday Problems During The Past Four Weeks
Hot Flashes
Headaches
Difficulty with bladder control (at other times)
Vaginal discharge
Vaginal bleeding or spotting
Genital itching/irritation
Vaginal dryness
Pain with intercourse
Breast pain
Difficulty with breast skin
Breast sensitivity/tenderness
General aches and pains
Joint pains
Muscle stiffness
Weight gain
Weight loss
Unhappy with appearance of my body
Decreased appetite
Forgetfulness
Excitability
Short temper
Tendency to take naps; stay in bed
Night sweats
Cold sweats
Difficulty concentrating
Easily distracted
Trouble sleeping
Early awakening
Any other problems
Severity
Overall health
In general, would you say your health is
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf (2)
Climbing several flights of stairs (3)
Accomplished less than you would like. (6)
Were limited in the kind of work or other activities. (5)
Didn't do work or other activities as carefully as usual. (7)
During the past 4 weeks, how much did pain interfere with your normal work? (8. including both work outside the home and housework)
Mood
Have you felt calm and peaceful? (9)
Did you feel full of pep? (10)
Did you have a lot of energy? (11)
Did you feel worn out? (12)
Did you feel tired? (13)
Have you felt downhearted and blue? (14)
During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities? (15. like visiting with friends, relatives, etc.)
Please score your overall quality of life as of today on an 11-point scale where 0 indicates being in the worst possible health and 10 indicates being in perfect health. (16)
Sexual activity
Have you been sexually active during the past SIX MONTHS? (17)
Lack of sexual interest
Difficulty in becoming sexually aroused
Unable to relax and enjoy sex
Difficulty in having orgasm

Similar models

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial