ID
6217
Beschreibung
CALGB: ADHERENCE QUESTIONNAIRE FORM (FOLLOW-UP) Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50CC350-FC34-364B-E034-080020C9C0E0
Link
Stichworte
Versionen (2)
- 18.12.14 18.12.14 - Martin Dugas
- 24.03.15 24.03.15 - Martin Dugas
Hochgeladen am
18. Dezember 2014
DOI
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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00024102 Quality of Life - CALGB: ADHERENCE QUESTIONNAIRE FORM (FOLLOW-UP) - 2044166v3.0
INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
Beschreibung
Unnamed2
Beschreibung
Patient'sName
Datentyp
text
Beschreibung
ParticipatingGroup
Datentyp
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Beschreibung
PatientHospitalNumber
Datentyp
text
Beschreibung
ParticipatingGroupProtocolNo.
Datentyp
text
Beschreibung
MainMemberInstitution/Adjunct
Datentyp
text
Beschreibung
ParticipatingGroupPatientNo.
Datentyp
text
Beschreibung
Unnamed3
Beschreibung
Unnamed4
Beschreibung
ThebenefitsofmycancertreatmentoutweighthedifficultiesIhaveinfollowingit.
Datentyp
text
Beschreibung
IbelievethattakingmycancermedicationistoomuchtroubleforwhatIwillgetoutofit.
Datentyp
text
Beschreibung
Becausetheschedulefortakingmycancermedicationistoodifficult,itisnotbeworthfollowingit.
Datentyp
text
Beschreibung
Takingmycancermedicationisbetterformethannottakingit.
Datentyp
text
Beschreibung
Takingmycancermedicationishelpingmetobehealthy.
Datentyp
text
Beschreibung
Unnamed5
Beschreibung
Unnamed6
Beschreibung
IwillbejustashealthyevenifIwerenottakingmycancermedication.
Datentyp
text
Beschreibung
Ibelievethatmycancertreatmentishelpingtocuremeofcancer.
Datentyp
text
Beschreibung
Itishardtobelievethatmycancertreatmentishelpingme.
Datentyp
text
Beschreibung
Lotsofthingsaregettinginthewayoffollowingtheschedulefortakingmycancermedication.
Datentyp
text
Beschreibung
Ineedmoreassistanceinordertofollowtheschedulefortakingmycancermedication.
Datentyp
text
Beschreibung
IamgettingthehelpIneedtofollowmycancermedicationschedule.
Datentyp
text
Beschreibung
Iamabletodealwithanyproblemsintakingmycancermedication.
Datentyp
text
Beschreibung
Thesideeffectsofmycancermedicationdisruptmynormalactivities.
Datentyp
text
Beschreibung
Ccrr Module For Calgb: Adherence Questionnaire Form (follow-up)
Ähnliche Modelle
INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)