Description:

NSABP Protocol R-04 Quality of Life Radiation Therapy and Either Capecitabine or Fluorouracil With or Without Oxaliplatin Before Surgery in Treating Patients With Resectable Rectal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B781948E-B324-266C-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B781948E-B324-266C-E034-0003BA12F5E7

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Versions (4) ▾
  1. 8/11/14
  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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Colorectal Cancer NCT00058474 Quality of Life - NSABP Protocol R-04 Quality of Life - 2086124v3.0

INSTRUCTIONS (ITEMS 56 - 72)

  1. StudyEvent: NSABP Protocol R-04 Quality of Life
    1. INSTRUCTIONS (ITEMS 56 - 72)
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
Social/family Well-being
I feel close to my friends
I get emotional support from my family
I get support from my friends
My family has accepted my illness
I am satisfied with family communication about my illness
I feel close to my partner (or the person who is my main support) (Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please check this box and go to the next section.)
I am satisfied with my sex life
Emotional Well-being
I feel sad
I am satisfied with how I am coping with my illness
I am losing hope in the fight against my illness
I feel nervous
I worry about dying
I worry that my condition will get worse
Functional Well-being
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 content with the quality of my life right now
I am content with the quality of my life right now
Additional Concerns
I have swelling or cramps in my stomach area
I am losing weight
I have control of my bowels
I have diarrhea
I have a good appetite
I like the appearance of my body
Do you have an ostomy appliance?
I am embarrassed by my ostomy appliance
Caring for my ostomy appliance is difficult
Additional Concerns
I feel fatigued
I feel weak all over
I feel listless ("washed out")
I feel tired
I have trouble starting things because I am tired
I have trouble finishing things because I am tired
I have energy
I am able to do my usual activities
I need to sleep during the day
I am too tired to eat
I need help doing my usual activities
I am frustrated by being too tired to do the things I want to do
I have to limit my social activity because I am tired
Did you feel full of life?
Did you have a lot of energy?
Did you feel worn out?
Did you feel tired? (Please indicate how much you have been bothered by each of the following problems during the past 7 days. )
Diarrhea
Abdominal pain or cramping
Gas pain
Mouth sores
Vomiting
Constipation
Skin problems (rash, irritation, redness)
Skin redness or peeling on hands and feet
Fever or shivering (shaking, chills)
Numbness or tingling in the hands or feet
Hair Loss
Chest Pain
Shortness of breath
Pain at intravenous (I.V.) site
Eye Problems (irritation or redness)
Hearing problems (ringing in the ears)
Other problems
Did you urinate frequently during the day?
Did you urinate frequently during the night?
Did you have pain when you urinated?
Did you have a bloated feeling in your abdomen?
Did you have abdominal pain?
Did you have pain in your buttocks?
Were you bothered by gas (flatulence)?
Did you belch?
Have you lost weight?
Did you have a dry mouth?
Have you had thin or lifeless hair as a result of your disease?
Did food and drink taste different from usual?
Have you felt physically less attractive as a result of your disease or treatment?
Have you been feeling less feminine/masculine as a result of your disease or treatment?
Have you been dissatisfied with your body?
Were you worried about your health in the future?
During The Past Four Weeks:
To what extent were you interested in sex?
To what extent were you sexually active (with or without intercourse)?
To what extent was sex enjoyable for you?
During The Past Four Weeks:
Did you have difficulty getting or maintaining an erection?
Did you have problems with ejaculation (e.g., so called "dry ejaculation")? ( Patients sometimes report that they have the following symptoms or problems. Please indicate the extent to which you have experienced these symptoms or problems during the past week. Please answer by circling the number that best applies to you.)
Did you have a dry vagina during intercourse?
Did you have pain during intercourse?
Do you have a stoma (colostomy bag)? (During the past week:)
Did you have frequent bowel movements during the day?
Did you have frequent bowel movements during the night?
Did you feel the urge to move your bowels without actually producing any stools?
Have you had any unintentional release of stools?
Have you had blood with your stools?
Have you had difficulty in moving your bowels?
Have your bowel movements been painful? (Only for patients WITH a stoma colostomy bag:)
Were you afraid that other people would be able to hear your stoma?
Were you afraid that other people would be able to smell your stools?
Were you worried about possible leakage from the stoma bag?
Did you have problems with caring for your stoma?
Was your skin around the stoma irritated?
Did you feel embarrassed because of your stoma?
Did you feel less complete because of your stoma? (During the past month, how would you describe your experience with your treatment. )
Receiving treatment is convenient for me
I am satisfied with my current treatment...........
Ccrr Module For Nsabp Protocol R-04 Quality Of Life
Are data amended?
Time Point for this Questionnaire
Post-Surgery Chemotherapy Agents
This form is being filled out:

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