Description:

Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer NCT00024102 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A55B50C6-E69C-4D72-E034-080020C9C0E0

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A55B50C6-E69C-4D72-E034-080020C9C0E0

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Versions (2) ▾
  1. 12/18/14
  2. 3/20/15
Uploaded on:

March 20, 2015

DOI:
No DOI assigned. To request one pleaselog in.
License:
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer (NCT00024102)

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.

Header
Amended data?
Patient characteristics
Other cancers or leukemia
How much does it interfere with your activities: Other cancers or leukemia (b.)
Arthritis, rheumatism, or other connective tissue disorders (b.)
How much does it interfere with your activities: Arthritis, rheumatism, or other connective tissue disorders (c.)
Glaucoma (c.)
How much does it interfere with your activities: Glaucoma (d.)
Emphysema or Chronic Bronchitis (d.)
How much does it interfere with your activities: Emphysema or Chronic Bronchitis (e.)
High Blood Pressure (e.)
How much does it interfere with your activities: High Blood Pressure (f.)
Heart disease (f.)
How much does it interfere with your activities: Heart disease (g.)
Circulation trouble in arms or legs (g.)
How much does it interfere with your activities: Circulation trouble in arms or legs (h.)
Diabetes (h.)
How much does it interfere with your activities: Diabetes (i.)
Stomach or intestinal disorders (i.)
How much does it interfere with your activities: Stomach or intestinal disorders (j.)
Osteoporosis (j.)
How much does it interfere with your activities: Osteoporosis (k.)
Chronic Liver or Kidney Disease (k.)
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
Stroke (l.)
How much does it interfere with your activities: Stroke (m.)
Depression (m.)
How much does it interfere with your activities: Depression
How is your eyesight (with glasses or contacts)? (mark one with an X)
If fair, poor or totally blind, how much does this interfere with your activities? (mark one with an X)
How is your hearing (with a hearing aid, if needed)? (mark one with an X)
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
how much does this interfere with your activities? (mark one with an X)
About how many times have you seen a doctor during the past 3 months, other than as an inpatient in a hospital? (6.)
During the past 3 months, how many days were you so sick that you were unable to carry out your usual activities - such as going to work or working around the house? (mark one with an X)
How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
Counseling
Since you were diagnosed with cancer, have you had any treatment or counseling for personal or family problems, or for nervous or emotional problems? (8b.)
What type of counseling or treatment did you receive? (mark all that apply with an X)
Check any of these services that you are still receiving (mark all that apply with an X)
Have you received any counseling or treatment for personal, family or emotional problems, since that last time you were interviewed? (If Yes)
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
Medication
Medicine to treat nausea and/or vomiting
Medicine to treat diarrhea
Medicine to reduce feeling very tired [fatigue]
Medicine to reduce swelling in hands or feet
Medicine or cream to treat mouth sores
Pain medicine for hands or feet
Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet
Other, specify
Arthritis medicine (If Taken, How Often?)
If Taken, How Often: Arthritis medicine (b.)
Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
Over-the counter pain killers (c.)
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
High blood pressure medicine (d.)
If Taken, How Often: High blood pressure medicine (e.)
Pills to make you lose water or salt (water pills or diuretics and not due to side effects from cancer treatment)
If Taken, How Often: Pills to make you lose water or salt (f.)
Digoxin pills for the heart (Lanoxin)
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
Nitroglycerin for chest pain (tablets or patches)
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
Blood thinner medicine (anticoagulants)
If Taken, How Often: Blood thinner medicine (anticoagulants)
Medicine to improve circulation (i.)
If Taken, How Often: Medicine to improve circulation (j.)
Insulin injections for diabetes (j.)
If Taken, How Often: Insulin injections for diabetes (k.)
Pills for diabetes (k.)
If Taken, How Often: Pills for diabetes (l.)
Ulcer medicine (l.)
If Taken, How Often: Ulcer medicine (m.)
Asthma medicines (m.)
If Taken, How Often: Asthma medicines (n.)
Seizure medicines (like Dilantin)
If Taken, How Often: Seizure medicines (like Dilantin)
Thyroid pills (If Taken, How Often?)
If Taken, How Often: Thyroid pills (p.)
Cortisone pills or injections (p.)
If Taken, How Often: Cortisone pills or injections (q.)
Antibiotics (q.)
If Taken, How Often: Antibiotics (r.)
Tranquilizers or medicine for your nerves (r.)
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
Prescription sleeping pills (s.)
If Taken, How Often: Prescription sleeping pills (t.)
Over-the-counter pills to help you sleep (t.)
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
Hormones (male or female)
If Taken, How Often: Hormones (v.)
Allergy medicines (v.)
If Taken, How Often: Allergy medicines (w.)
Laxatives (w.)
If Taken, How Often: Laxatives (x.)
Eye drops for glaucoma (x.)
If Taken, How Often: Eye drops for glaucoma (y.)
Calcium tablets (y.)
If Taken, How Often: Calcium tablets (z.)
Vitamins and/or minerals (other than calcium)
If Taken, How Often: Vitamins and/or minerals (other than calcium)
Herbal medicines (aa.)
If Taken, How Often: Herbal medicines (12.)
Have you taken any other medicines in the past month?
If Taken, How Often?