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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

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

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C50-C50

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26-08-12 26-08-12 -
08-01-15 08-01-15 - Martin Dugas

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26 augustus 2012

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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

Engels 1

Engels

Details

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 Formulieren

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

Unnamed1

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)

Unnamed1

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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