Description:

CALGB-40502 Health Survey NCT00785291 Paclitaxel, Paclitaxel Albumin-Stabilized Nanoparticle Formulation, or Ixabepilone With or Without Bevacizumab in Treating Patients With Stage IIIC or Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=523BB798-CD9E-215F-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=523BB798-CD9E-215F-E044-0003BA3F9857

Keywords:
Versions (4) ▾
  1. 8/27/12
  2. 1/9/15
  3. 1/9/15
  4. 7/3/15
Uploaded on:

July 3, 2015

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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CALGB-40502 Health Survey NCT00785291

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink.

Header
Are data amended
Patient demographics
Health Before Cancer Diagnosis
Do you have heart disease
Do you have high blood pressure
Do you have emphysema or bronchitis
Do you have diabetes
Do you have ulcers or stomach disease
Do you have kidney disease
Do you have anemia or other blood disease
Do you have depression
Do you have arthritis
Do you get treatment for it
Does it limit your activities
Section Ii - Social Support
Someone you can count on to listen when you need to talk
Some whose advice you really want
Some whose advice you really want
Someone to share your most private worries and fears with
Someone to share your most private worries and fears with
Someone to turn to for suggestions about how to deal with a personal problem
Someone to turn to for suggestions about how to deal with a personal problem
Someone who understands your problems
Section Ii - Social Support
Someone to do something enjoyable with
Someone to do something enjoyable with
Someone to do things with, to help you get your mind off things
Someone to do things with, to help you get your mind off things
Section Ii - Social Support
Someone to help you if you were confined to bed
Someone to take you to the doctor if you needed it
Someone to prepare meals if you were unable to do it yourself
Someone to help with daily chores if you were sick
Someone to turn to for suggestions about how to deal with a personal problem
Someone to turn to for suggestions about how to deal with a personal problem
Section Ii - Social Support
Someone to love and make you feel wanted
Someone to love and make you feel wanted
Someone who hugs you
Section Iii - Demographics
Race
Ethnicity
What is the highest grade you finished in school?
Marital status
Is the place where you live
Method of Payment (The type of health insurance do you currently have)
When you go to the drug store to get your medications, do you have trouble coming up with the money to pay for them
Household Income (your best estimate of your family income last year, including income from all sources, before taxes)

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