Description:

CALGB: ADHERENCE QUESTIONNAIRE FORM (FOLLOW-UP) 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=A50CC350-FC34-364B-E034-080020C9C0E0

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50CC350-FC34-364B-E034-080020C9C0E0

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Versions (2) ▾
  1. 12/18/14
  2. 3/24/15
Uploaded on:

March 24, 2015

DOI:
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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?
Compliance behavior
The benefits of my cancer treatment outweigh the difficulties I have in following it. (2.)
I believe that taking my cancer medication is too much trouble for what I will get out of it. (3.)
Because the schedule for taking my cancer medication is too difficult, it is not be worth following it. (4.)
Taking my cancer medication is better for me than not taking it. (5.)
Taking my cancer medication is helping me to be healthy.
I will be just as healthy even if I were not taking my cancer medication. (7.)
I believe that my cancer treatment is helping to cure me of cancer. (8.)
It is hard to believe that my cancer treatment is helping me. (9.)
Lots of things are getting in the way of following the schedule for taking my cancer medication. (10.)
I need more assistance in order to follow the schedule for taking my cancer medication. (11.)
I am getting the help I need to follow my cancer medication schedule. (12.)
I am able to deal with any problems in taking my cancer medication. (13.)
The side effects of my cancer medication disrupt my normal activities.