PACCT-1 TAILORx FACT - Fatique Scale Form NCT00310180 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:


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June 8, 2015

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PACCT-1 TAILORx FACT - Fatique Scale Form NCT00310180

INSTRUCTIONS: Please complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center. Keep a copy for your files

Report Period on Treatment
Report Period (since start of Step 2 Choose one)
Data amendment
Are data amended
Assessment Date
Additional Concerns
I feel fatigued
I feel weak all over
I feel listless ("washed out")
I feel tired
I have trouble starting things because I am tired
I have trouble finishing things because I am tired
I have energy
I am able to do my usual activities
I need to sleep during the day
I am too tired to eat
I need help doing my usual activities
I am frustrated by being too tired to do the things I want to do
I have to limit my social activity because I am tired

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