Description:

FACT-B (Version 4), E2100 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC2FF0E4-063C-2184-E034-0003BA12F5E7

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC2FF0E4-063C-2184-E034-0003BA12F5E7
Keywords:
  1. 8/27/12 8/27/12 -
  2. 5/23/15 5/23/15 -
Uploaded on:

May 23, 2015

DOI:
To request one please log in.
License :
Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

FACT-B (Version 4), E2100

Form No. 1576

  1. StudyEvent: FACT-B (Version 4), E2100
    1. Form No. 1576
ECOG clinical trial administrative data
Physical Well-being
I have a lack of energy (GP2)
I have nausea (GP3)
Because of my physical condition, I have trouble meeting the needs of my family (GP4)
I have pain (GP5)
I am bothered by side effects of treatment (GP6)
I feel ill (GP7)
I am forced to spend time in bed (GS1)
Social/family Well-being
I feel close to my friends (GS2)
I get emotional support from my family (GS3)
I get support from my friends (GS4)
My family has accepted my illness (GS5)
I am satisfied with communication about my illness (GS6)
I feel close to my partner (or the person who is my main support)
I am satisfied with my sex life.
Emotional Well-being
I feel sad (GE2)
I am satisfied with how I am coping with my illness (GE3)
I am losing hope in the fight against my illness (GE4)
I feel nervous (GE5)
I worry about dying (GE6)
I worry that my condition will get worse (GF1)
Functional Well-being
I am able to work (include work at home) (GF2)
My work (include work at home) is fulfilling (GF3)
I am able to enjoy life (GF4)
I have accepted my illness (GF5)
I am sleeping well (GF6)
I am enjoying things I usually do for fun (GF7)
I am content with the quality of my life right now
Additional Concerns
I have been short of breath (B2)
I am self-concious about the way I dress (B3)
One or both of my arms are swollen and tender (B4)
I feel sexually attractive (B5)
I am bothered by my hair loss (B6)
I worry that other members of my family might someday get the same illness I have (B7)
I worry about the effects of stress on my illness (B8)
I am bothered by a change in weight (B9)
I am able to feel like a woman
Ccrr Module For Fact-b (version 4), E2100

Similar models

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial