ID

1381

Descrizione

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

collegamento

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

Keywords

versioni (2)
  1. 27/08/12 27/08/12 -
  2. 14/07/17 14/07/17 - Martin Dugas
Caricato su

27 agosto 2012

DOI

Per favore, per richiedere un accesso.

Licenza

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

Inglese

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 moduli  
Ccrr Module For Calgb: Fact/gog Neurotoxicity Subscale
Descrizione

Ccrr Module For Calgb: Fact/gog Neurotoxicity Subscale

Patient Initials
Descrizione

PatientInitials

Tipo di dati

text

Patient Hospital No.
Descrizione

PatientHospitalNo.

Tipo di dati

text

Institution/Affiliate
Descrizione

Institution/Affiliate

Tipo di dati

text

Participating Group
Descrizione

ParticipatingGroup

Tipo di dati

text

Participating Group Protocol No.
Descrizione

ParticipatingGroupProtocolNo.

Tipo di dati

text

Participating Group Patient ID
Descrizione

ParticipatingGroupPatientID

Tipo di dati

text

Interviewer or CRA
Descrizione

InterviewerorCRA

Tipo di dati

text

Assessment Number
Descrizione

AssessmentNumber

Tipo di dati

text

I have numbness or tingling in my hands
Descrizione

Ihavenumbnessortinglinginmyhands

Tipo di dati

text

I have numbness or tingling in my feet
Descrizione

Ihavenumbnessortinglinginmyfeet

Tipo di dati

text

I feel discomfort in my hands
Descrizione

Ifeeldiscomfortinmyhands

Tipo di dati

text

I have discomfort in my feet
Descrizione

Ihavediscomfortinmyfeet

Tipo di dati

text

I have joint pain or muscles cramps
Descrizione

Ihavejointpainormusclescramps

Tipo di dati

text

I feel weak all over
Descrizione

Ifeelweakallover

Tipo di dati

text

I have trouble hearing
Descrizione

Ihavetroublehearing

Tipo di dati

text

I get ringing or buzzing in my ears
Descrizione

Igetringingorbuzzinginmyears

Tipo di dati

text

I have trouble buttoning buttons
Descrizione

Ihavetroublebuttoningbuttons

Tipo di dati

text

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

Ihavetroublefeelingtheshapeofsmallobjectswhentheyareinmyhand.

Tipo di dati

text

I have trouble walking.
Descrizione

Ihavetroublewalking.

Tipo di dati

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 moduli
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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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