Description:

GOG-0241 Quality of Life Survey Form Carboplatin and Paclitaxel or Oxaliplatin and Capecitabine, With or Without Bevacizumab, as First-Line Therapy in Treating Patients With Newly Diagnosed Stage II, Stage III, Stage IV, or Recurrent Stage I Epithelial Ovarian Cancer or Fallopian Tube Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8D16EFA4-532E-082B-E040-BB89AD434B01

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8D16EFA4-532E-082B-E040-BB89AD434B01

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Versions (4) ▾
  1. 9/19/12
  2. 8/11/14
  3. 1/9/15
  4. 9/20/21
Uploaded on:

September 20, 2021

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License:
Creative Commons BY-NC 3.0 Legacy
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Fallopian Tube Cancer NCT01081262 Quality of Life - GOG-0241 Quality of Life Survey Form - 3126513v1.0

Below is a list of statements that other people with your illness have said are important. Please circle or mark one number per line to indicate your response as it applies to the past 7 days

Header Module
Qol Questionnaire Administration
Scheduled time to obtain Quality of Life Questionnaire (Mark one)
Physical Well-being
I have a lack of energy.
I have nausea.
Because of my physical condition, I have trouble meeting the needs of my family.
I have pain.
I am bothered by side effects of treatment.
I feel ill
I am forced to spend time in bed
Functional Wellbeing
I am able to work (include work at home)
My work (include work at home) is fulfilling
I am able to enjoy life.
I have accepted my illness
I am sleeping well
I am enjoying the things I usually do for fun
I am content with the quality of my life right now
Additional Concerns
I have swelling in my stomach area
I am losing weight
I have control of my bowels
I have been vomiting
I am bothered by hair loss.
I have a good appetite
I like the appearance of my body
I am able to get around by myself
I am able to feel like a woman.
I have cramps in my stomach area
I am interested in sex
I have concerns about my ability to have children
Ntx4 Subscale
I have numbness or tingling in my hands
I have numbness or tingling in my feet
I feel discomfort in my hands
I feel discomfort in my feet
Unamed Module 2
Mobility
Self care
Usual activities (e.g. work, study, housework, family, or leisure activities)
Pain/discomfort
Anxiety/depression
Unnamed Module 3
To Be Completed By Clinical Staff
Status of the QOL assessment

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