ID

1381

Beschrijving

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

Trefwoorden

Versies (2)
  1. 27-08-12 27-08-12 -
  2. 14-07-17 14-07-17 - Martin Dugas
Geüploaded op

27 augustus 2012

DOI

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Licentie

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

Engels

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 Formulieren  
Ccrr Module For Calgb: Fact/gog Neurotoxicity Subscale
Beschrijving

Ccrr Module For Calgb: Fact/gog Neurotoxicity Subscale

Patient Initials
Beschrijving

PatientInitials

Datatype

text

Patient Hospital No.
Beschrijving

PatientHospitalNo.

Datatype

text

Institution/Affiliate
Beschrijving

Institution/Affiliate

Datatype

text

Participating Group
Beschrijving

ParticipatingGroup

Datatype

text

Participating Group Protocol No.
Beschrijving

ParticipatingGroupProtocolNo.

Datatype

text

Participating Group Patient ID
Beschrijving

ParticipatingGroupPatientID

Datatype

text

Interviewer or CRA
Beschrijving

InterviewerorCRA

Datatype

text

Assessment Number
Beschrijving

AssessmentNumber

Datatype

text

I have numbness or tingling in my hands
Beschrijving

Ihavenumbnessortinglinginmyhands

Datatype

text

I have numbness or tingling in my feet
Beschrijving

Ihavenumbnessortinglinginmyfeet

Datatype

text

I feel discomfort in my hands
Beschrijving

Ifeeldiscomfortinmyhands

Datatype

text

I have discomfort in my feet
Beschrijving

Ihavediscomfortinmyfeet

Datatype

text

I have joint pain or muscles cramps
Beschrijving

Ihavejointpainormusclescramps

Datatype

text

I feel weak all over
Beschrijving

Ifeelweakallover

Datatype

text

I have trouble hearing
Beschrijving

Ihavetroublehearing

Datatype

text

I get ringing or buzzing in my ears
Beschrijving

Igetringingorbuzzinginmyears

Datatype

text

I have trouble buttoning buttons
Beschrijving

Ihavetroublebuttoningbuttons

Datatype

text

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

Ihavetroublefeelingtheshapeofsmallobjectswhentheyareinmyhand.

Datatype

text

I have trouble walking.
Beschrijving

Ihavetroublewalking.

Datatype

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 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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