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PACCT-1 TAILORx FACT - General Form Hormone Therapy With or Without Combination Chemotherapy in Treating Women Who Have Undergone Surgery for Node-Negative Breast Cancer (The TAILORx Trial) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=84B142E1-7E5A-582E-E040-BB89AD436C2E

Lien:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=84B142E1-7E5A-582E-E040-BB89AD436C2E

Mots-clés:

D016430

Lebensqualität

C50

Versions (2)

26/08/2012 26/08/2012 -
08/01/2015 08/01/2015 - Martin Dugas

Téléchargé le:

8 janvier 2015

DOI:

Pour une demande vous connecter.

Licence :

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer NCT00310180 Quality of Life - PACCT-1 TAILORx FACT - General Form - 3071611v1.0

Anglais 1

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Détails

INSTRUCTIONS: Please complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center. Keep a copy for your files

1 Formulaires

StudyEvent: PACCT-1 TAILORx FACT - General Form
1. INSTRUCTIONS: Please complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center. Keep a copy for your files

Header

ECOG Protocol Number

ECOG Patient ID

DCI Name

On Treatment

Report Period (since start of Step 2 Choose one)

Baseline (baseline)

12 Months (12 months)

36 Months (36 months)

Unnamed2

Please mark an 'X' if data have been amended. (Please circle amended items in red)

Date data amended (s M D Y)

Header

Date of Assessment

Physical Well-being

I have a lack of energy

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I have nausea

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

Because of my physical condition, I have trouble meeting the needs of my family

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I have pain

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I am bothered by side effects of treatment

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I feel ill

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I am forced to spend time in bed

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

Social/family Well-being

I feel close to my friends

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I get emotional support from my family

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I get support from my friends

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

My family has accepted my illness

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I am satisfied with family communication about my illness

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I feel close to my partner (or the person who is my main support)

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please check this box and go to the next section.

I am satisfied with my sex life

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

Emotional Well-being

I feel sad

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I am satisfied with how I am coping with my illness

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I am losing hope in the fight against my illness

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I feel nervous

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I worry about dying

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I worry that my condition will get worse

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

Functional Well-being

I am able to work (include work at home)

1 (Not at all)

2 (A little bit)

3 (Somewhat)

4 (Quite a bit)

5 (Very much)

My work is fulfilling (include work at home)

1 (Not at all)

2 (A little bit)

3 (Somewhat)

4 (Quite a bit)

5 (Very much)

I am able to enjoy life

1 (Not at all)

2 (A little bit)

3 (Somewhat)

4 (Quite a bit)

5 (Very much)

I have accepted my illness

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I am sleeping well

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I am enjoying the things I usually do for fun

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I am content with the quality of my life right now

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

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Breast Cancer NCT00310180 Quality of Life - PACCT-1 TAILORx FACT - General Form - 3071611v1.0

INSTRUCTIONS: Please complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center. Keep a copy for your files

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