FACT-B (Version 4), E2100 Source Form: NCI FormBuilder:


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May 23, 2015

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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

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