Description:

CALGB Memorial Symptom Assessment Scale Condensed Form NCT00390455 Fulvestrant With or Without Lapatinib in Treating Postmenopausal Women With Stage III or Stage IV Breast Cancer That is Hormone Receptor-Positive Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0D7D5091-6484-2392-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0D7D5091-6484-2392-E044-0003BA3F9857

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Versions (4) ▾
  1. 8/26/12
  2. 1/9/15
  3. 6/21/15
  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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CALGB Memorial Symptom Assessment Scale Condensed Form NCT00390455

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink.

Header
Are data amended
Patient demographics
Memorial Symptom Assessment
Lack of energy (DURING THE PAST 7 DAYS, did you have any of the following symptoms?)
Lack of energy (If YES, how much did it DISTRESS or BOTHER you?)
Lack of appetite (DURING THE PAST 7 DAYS, did you have any of the following symptoms?)
Lack of appetite (If YES, how much did it DISTRESS or BOTHER you?)
Pain (DURING THE PAST 7 DAYS, did you have any of the following symptoms?)
Pain (If YES, how much did it DISTRESS or BOTHER you?)
Dry Mouth (DURING THE PAST 7 DAYS, did you have any of the following symptoms?)
Dry Mouth (If YES, how much did it DISTRESS or BOTHER you?)
Weight loss (DURING THE PAST 7 DAYS, did you have any of the following symptoms?)
Weight loss (If YES, how much did it DISTRESS or BOTHER you?)
Feeling drowsy (DURING THE PAST 7 DAYS, did you have any of the following symptoms?)
Feeling drowsy (If YES, how much did it DISTRESS or BOTHER you?)
Difficulty sleeping (DURING THE PAST 7 DAYS, did you have any of the following symptoms?)
Difficulty sleeping (If YES, how much did it DISTRESS or BOTHER you?)
Shortness of breath (DURING THE PAST 7 DAYS, did you have any of the following symptoms?)
Shortness of breath (If YES, how much did it DISTRESS or BOTHER you?)
Nausea (DURING THE PAST 7 DAYS, did you have any of the following symptoms?)
Nausea (If YES, how much did it DISTRESS or BOTHER you?)
Cough (DURING THE PAST 7 DAYS, did you have any of the following symptoms?)
Cough (If YES, how much did it DISTRESS or BOTHER you?)
Worrying (During the past 7 days did you have any of the following symptoms?)
Worrying (If YES, how OFTEN did it occur?)
Feeling sad (During the past 7 days did you have any of the following symptoms?)
Feeling sad (If YES, how OFTEN did it occur?)
Feeling nervous (During the past 7 days did you have any of the following symptoms?)
Feeling nervous (If YES, how OFTEN did it occur?)
Assessment of Quality of Life
How would you rate your overall quality of life during the past week? (Mark one with an X)

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