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E2805 FACIT-Fatique Subscale (Version 4) NCT00326898 Sunitinib or Sorafenib in Treating Patients With Kidney Cancer That Was Removed By Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6E9962A5-327A-5CEE-E040-BB89AD43557D

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6E9962A5-327A-5CEE-E040-BB89AD43557D

Keywords:

Clinical Trial

Quality of Life

Kidney Neoplasms

Versions (3)

9/19/12 9/19/12 -
1/9/15 1/9/15 - Martin Dugas
6/16/15 6/16/15 -

Uploaded on:

June 16, 2015

DOI:

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License :

Creative Commons BY-NC 3.0 Legacy

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E2805 FACIT-Fatique Subscale (Version 4) NCT00326898

English 1

English

Details

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

1 forms

StudyEvent: E2805 FACIT-Fatique Subscale (Version 4)
1. INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule).

Patient demographics

Patient Initials (Last, First)

ECOG Protocol Number

Participating Group Protocol Number

Institution/Affiliate

ECOG Patient ID

Participating Group Patient ID

Data amendment

Please mark an 'X' if data have been amended (Please circle amended items in red)

Date data amended (M D Y)

Additional Concerns

I feel fatigued

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

How often did you feel tired

Always (Always)

Never (Never)

Often (Often)

Rarely (Rarely)

Sometimes (Sometimes)

I feel weak all over

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I feel listless ("washed out")

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I have trouble starting things because I am tired

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I have trouble finishing things because I am tired

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I have energy

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I am able to do my usual activities

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I need to sleep during the day

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I am too tired to eat

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I need help doing my usual activities

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I am frustrated by being too tired to do the things I want to do

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

I have to limit my social activity because I am tired

Not At All (Not at all)

A Little Bit (A little bit)

Somewhat (Somewhat)

Quite A Bit (Quite a bit)

Very Much (Very much)

Fatigue - Short Form

How often did you feel tired

Always (Always)

Never (Never)

Often (Often)

Rarely (Rarely)

Sometimes (Sometimes)

How often did you experience extreme exhaustion

Always (Always)

Never (Never)

Often (Often)

Rarely (Rarely)

Sometimes (Sometimes)

How often did you run out of energy

Always (Always)

Never (Never)

Often (Often)

Rarely (Rarely)

Sometimes (Sometimes)

How often did your fatigue limit you at work (include work at home)

Always (Always)

Never (Never)

Often (Often)

Rarely (Rarely)

Sometimes (Sometimes)

How often were you too tired to think clearly

Always (Always)

Never (Never)

Often (Often)

Rarely (Rarely)

Sometimes (Sometimes)

How often were you too tired to take a bath or shower

Always (Always)

Never (Never)

Often (Often)

Rarely (Rarely)

Sometimes (Sometimes)

How often did you have enough energy to exercise strenuously

Always (Always)

Never (Never)

Often (Often)

Rarely (Rarely)

Sometimes (Sometimes)

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E2805 FACIT-Fatique Subscale (Version 4) NCT00326898

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

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