Description:

E1105 FACIT-Fatique Subscale (Version 4) NCT00520975 First-Line Chemotherapy and Trastuzumab With or Without Bevacizumab in Treating Patients With Metastatic Breast Cancer That Overexpresses HER-2/NEU Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1736471B-BF38-3BED-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1736471B-BF38-3BED-E044-0003BA3F9857

Keywords:
Versions (3) ▾
  1. 8/26/12
  2. 1/8/15
  3. 6/8/15
Uploaded on:

June 8, 2015

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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E1105 FACIT-Fatique Subscale (Version 4) NCT00520975

INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule).

Header
Reporting Period
On Treatment Report Period (Maintenance 1 cycle = 3 weeks)
On Treatment Report Period (Maintenance 1 cycle = 3 weeks)
Patient demographics
Data amendment
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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