RTOG 1010 EQ-5D Form and Cover Sheet (HP)

Amended data

Yes

No

Time point

Pretreatment (Pretreatment)

1 Year From Start Of Treatment (1 year from start of treatment)

2 Years From Start Of Treatment (2 years from start of treatment)

Was patient questionnaire completed

Yes

No

Reason Questionnaire was not Completed (PATIENT)

Not Applicable, Questionnaire Was Completed (Not applicable, questionnaire was completed)

Patient Refused Due To Illness (Patient refused due to illness)

Patient Refused For Other Reason (Patient refused for other reason)

Patient Unable To Be Contacted (Patient unable to be contacted)

Institution Error (Institutional error)

4 weitere Items in der Detailansicht.

Specify method of completion

Not Applicable (Not applicable)

At Appointment (At appointment)

By Mail (By mail)

By Telephone (By telephone)

Unknown (Unknown)

Did the patient require any assistance in completing the questionnaire?

Not Applicable (Not applicable)

No (No)

Yes (Yes)

Unknown If Assistance Given (Unknown if assistance given)

Specify the person who assisted the patient

Not Applicable (Not applicable)

Staff Member (Staff member)

Family (Family)

Other (Other)

Unknown (Unknown)

Extent of the assistance

Not Applicable (Not applicable)

Read Items To Patient (Read items to patient)

Interpreted Items For Patient (Interpreted items for patient)

Marked Items Per Patient's Response (Marked items per patient's response)

Combination Of Above (Combination of above)

3 weitere Items in der Detailansicht.