ID

1381

Descrição

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

Palavras-chave

  1. 27/08/2012 27/08/2012 -
  2. 14/07/2017 14/07/2017 - Martin Dugas
Transferido a

27 de agosto de 2012

DOI

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Licença

Creative Commons BY-NC 3.0

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Colorectal Cancer NCT00077233 Toxicity - CALGB: FACT/GOG NEUROTOXICITY SUBSCALE - 2170915v3.0

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.

Ccrr Module For Calgb: Fact/gog Neurotoxicity Subscale
Descrição

Ccrr Module For Calgb: Fact/gog Neurotoxicity Subscale

Patient Initials
Descrição

PatientInitials

Tipo de dados

text

Patient Hospital No.
Descrição

PatientHospitalNo.

Tipo de dados

text

Institution/Affiliate
Descrição

Institution/Affiliate

Tipo de dados

text

Participating Group
Descrição

ParticipatingGroup

Tipo de dados

text

Participating Group Protocol No.
Descrição

ParticipatingGroupProtocolNo.

Tipo de dados

text

Participating Group Patient ID
Descrição

ParticipatingGroupPatientID

Tipo de dados

text

Interviewer or CRA
Descrição

InterviewerorCRA

Tipo de dados

text

Assessment Number
Descrição

AssessmentNumber

Tipo de dados

text

I have numbness or tingling in my hands
Descrição

Ihavenumbnessortinglinginmyhands

Tipo de dados

text

I have numbness or tingling in my feet
Descrição

Ihavenumbnessortinglinginmyfeet

Tipo de dados

text

I feel discomfort in my hands
Descrição

Ifeeldiscomfortinmyhands

Tipo de dados

text

I have discomfort in my feet
Descrição

Ihavediscomfortinmyfeet

Tipo de dados

text

I have joint pain or muscles cramps
Descrição

Ihavejointpainormusclescramps

Tipo de dados

text

I feel weak all over
Descrição

Ifeelweakallover

Tipo de dados

text

I have trouble hearing
Descrição

Ihavetroublehearing

Tipo de dados

text

I get ringing or buzzing in my ears
Descrição

Igetringingorbuzzinginmyears

Tipo de dados

text

I have trouble buttoning buttons
Descrição

Ihavetroublebuttoningbuttons

Tipo de dados

text

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

Ihavetroublefeelingtheshapeofsmallobjectswhentheyareinmyhand.

Tipo de dados

text

I have trouble walking.
Descrição

Ihavetroublewalking.

Tipo de dados

text

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.

Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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
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
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
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
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
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
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
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
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
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
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
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
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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