ID

1381

Beskrivning

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

Länk

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

Nyckelord

Versioner (2)
  1. 2012-08-27 2012-08-27 -
  2. 2017-07-14 2017-07-14 - Martin Dugas
Uppladdad den

27 augusti 2012

DOI

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Licens

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

Engelsk

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 Formulär  
Ccrr Module For Calgb: Fact/gog Neurotoxicity Subscale
Beskrivning

Ccrr Module For Calgb: Fact/gog Neurotoxicity Subscale

Patient Initials
Beskrivning

PatientInitials

Datatyp

text

Patient Hospital No.
Beskrivning

PatientHospitalNo.

Datatyp

text

Institution/Affiliate
Beskrivning

Institution/Affiliate

Datatyp

text

Participating Group
Beskrivning

ParticipatingGroup

Datatyp

text

Participating Group Protocol No.
Beskrivning

ParticipatingGroupProtocolNo.

Datatyp

text

Participating Group Patient ID
Beskrivning

ParticipatingGroupPatientID

Datatyp

text

Interviewer or CRA
Beskrivning

InterviewerorCRA

Datatyp

text

Assessment Number
Beskrivning

AssessmentNumber

Datatyp

text

I have numbness or tingling in my hands
Beskrivning

Ihavenumbnessortinglinginmyhands

Datatyp

text

I have numbness or tingling in my feet
Beskrivning

Ihavenumbnessortinglinginmyfeet

Datatyp

text

I feel discomfort in my hands
Beskrivning

Ifeeldiscomfortinmyhands

Datatyp

text

I have discomfort in my feet
Beskrivning

Ihavediscomfortinmyfeet

Datatyp

text

I have joint pain or muscles cramps
Beskrivning

Ihavejointpainormusclescramps

Datatyp

text

I feel weak all over
Beskrivning

Ifeelweakallover

Datatyp

text

I have trouble hearing
Beskrivning

Ihavetroublehearing

Datatyp

text

I get ringing or buzzing in my ears
Beskrivning

Igetringingorbuzzinginmyears

Datatyp

text

I have trouble buttoning buttons
Beskrivning

Ihavetroublebuttoningbuttons

Datatyp

text

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

Ihavetroublefeelingtheshapeofsmallobjectswhentheyareinmyhand.

Datatyp

text

I have trouble walking.
Beskrivning

Ihavetroublewalking.

Datatyp

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 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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