Info
Diálogo
Transferência

Avaliação Avaliações

Descrição:

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

Link:

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

Palavras-chave:

D016430

D011788

C50-C50.9

Versões (2)

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

Transferido a:

8 de janeiro de 2015

DOI:

Para um pedido faça login.

Licença :

Creative Commons BY-NC 3.0 Legacy

Comentários do modelo :

Aqui pode comentar o modelo. Pode comentá-lo especificamente através dos balões de texto nos grupos de itens e itens.

Voltar para os comentários do modelo

Comentários do grupo de itens para :

Comentários do item para :

Para descarregar formulários, precisa de ter uma sessão iniciada. Por favor faça login ou registe-se gratuitamente.

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

Inglês 1

Inglês

Detalhes

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 Formulários

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)

Voltar ao início da página

Similar models

Show recommended models

Descrição:

Link:

Palavras-chave:

Versões (2)

Transferido a:

DOI:

Licença :

Comentários do modelo :

Comentários do grupo de itens para :

Comentários do item para :

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

Similar models

Contacto

Ajuda