ID

1381

Description

CALGB: FACT/GOG NEUROTOXICITY SUBSCALE Fluorouracil and Leucovorin Plus Either Irinotecan or Oxaliplatin With or Without Cetuximab in Treating Patients With Previously Untreated Metastatic Adenocarcinoma of the Colon or Rectum Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BFC4A282-B374-0499-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=BFC4A282-B374-0499-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/27/12 8/27/12 -
  2. 7/14/17 7/14/17 - Martin Dugas
Uploaded on

August 27, 2012

DOI

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License

Creative Commons BY-NC 3.0
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Colorectal Cancer NCT00077233 Toxicity - CALGB: FACT/GOG NEUROTOXICITY SUBSCALE - 2170915v3.0

English

PATIENT INSTRUCTIONS: By marking one box per line with an X, indicating how true each statement has been for you during the past 7 days.

1 forms  
Ccrr Module For Calgb: Fact/gog Neurotoxicity Subscale
Description

Ccrr Module For Calgb: Fact/gog Neurotoxicity Subscale

Patient Initials
Description

PatientInitials

Data type

text

Patient Hospital No.
Description

PatientHospitalNo.

Data type

text

Institution/Affiliate
Description

Institution/Affiliate

Data type

text

Participating Group
Description

ParticipatingGroup

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Participating Group Patient ID
Description

ParticipatingGroupPatientID

Data type

text

Interviewer or CRA
Description

InterviewerorCRA

Data type

text

Assessment Number
Description

AssessmentNumber

Data type

text

I have numbness or tingling in my hands
Description

Ihavenumbnessortinglinginmyhands

Data type

text

I have numbness or tingling in my feet
Description

Ihavenumbnessortinglinginmyfeet

Data type

text

I feel discomfort in my hands
Description

Ifeeldiscomfortinmyhands

Data type

text

I have discomfort in my feet
Description

Ihavediscomfortinmyfeet

Data type

text

I have joint pain or muscles cramps
Description

Ihavejointpainormusclescramps

Data type

text

I feel weak all over
Description

Ifeelweakallover

Data type

text

I have trouble hearing
Description

Ihavetroublehearing

Data type

text

I get ringing or buzzing in my ears
Description

Igetringingorbuzzinginmyears

Data type

text

I have trouble buttoning buttons
Description

Ihavetroublebuttoningbuttons

Data type

text

I have trouble feeling the shape of small objects when they are in my hand.
Description

Ihavetroublefeelingtheshapeofsmallobjectswhentheyareinmyhand.

Data type

text

I have trouble walking.
Description

Ihavetroublewalking.

Data type

text

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Similar models

PATIENT INSTRUCTIONS: By marking one box per line with an X, indicating how true each statement has been for you during the past 7 days.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Calgb: Fact/gog Neurotoxicity Subscale
PatientInitials
Item
Patient Initials
text
PatientHospitalNo.
Item
Patient Hospital No.
text
Institution/Affiliate
Item
Institution/Affiliate
text
ParticipatingGroup
Item
Participating Group
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
InterviewerorCRA
Item
Interviewer or CRA
text
Item
Assessment Number
text
CL.1
Code List
Assessment Number
CL Item
7 Day (7 Day)
CL Item
30 Day (30 Day)
Item
I have numbness or tingling in my hands
text
CL.2
Code List
I have numbness or tingling in my hands
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I have numbness or tingling in my feet
text
CL.3
Code List
I have numbness or tingling in my feet
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I feel discomfort in my hands
text
CL.4
Code List
I feel discomfort in my hands
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I have discomfort in my feet
text
CL.5
Code List
I have discomfort in my feet
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I have joint pain or muscles cramps
text
CL.6
Code List
I have joint pain or muscles cramps
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I feel weak all over
text
CL.7
Code List
I feel weak all over
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I have trouble hearing
text
CL.8
Code List
I have trouble hearing
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I get ringing or buzzing in my ears
text
CL.9
Code List
I get ringing or buzzing in my ears
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I have trouble buttoning buttons
text
CL.10
Code List
I have trouble buttoning buttons
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I have trouble feeling the shape of small objects when they are in my hand.
text
CL.11
Code List
I have trouble feeling the shape of small objects when they are in my hand.
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
Item
I have trouble walking.
text
CL.12
Code List
I have trouble walking.
CL Item
Not at all (Not at all)
CL Item
A little bit (A little bit)
CL Item
Somewhat (Somewhat)
CL Item
Quite a bit (Quite a bit)
CL Item
Very much (Very much)
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