Description:

NCT00113399 RTOG-0421 HP: Radiation Therapy Oncology Group Health Utility Measurement Euro (EQ-5D) Miscellaneous Patient Assessment Form Combination Chemotherapy With or Without Radiation Therapy in Treating Patients With Recurrent Head and Neck Cancer That Cannot Be Removed By Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EBAEDD99-A13F-1374-E034-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EBAEDD99-A13F-1374-E034-0003BA3F9857

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Versions (2) ▾
  1. 7/2/17
  2. 9/20/21
Uploaded on:

September 20, 2021

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License:
Creative Commons BY-NC 3.0 Legacy
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NCT00113399 RTOG-0421 HP: Radiation Therapy Oncology Group Health Utility Measurement Euro (EQ-5D) Miscellaneous Patient Assessment Form

No Instruction available.

  1. StudyEvent: RTOG-0421 HP: Radiation Therapy Oncology Group Health Utility Measurement Euro (EQ-5D) Miscellaneous Patient Assessment Form
    1. No Instruction available.
RTOG clinical trial administrative data
Amended data
Miscellaneous Patient Assessment
HAVE YOU EXPERIENCED SERIOUS ILLNESS In yourself?
HAVE YOU EXPERIENCED SERIOUS ILLNESS In your family?
HAVE YOU EXPERIENCED SERIOUS ILLNESS In caring for others?
ARE YOU
ARE YOU A current smoker
ARE YOU An ex-smoker
ARE YOU A never smoker
DO YOU NOW, OR DID YOU EVER, WORK IN HEALTH OR SOCIAL SERVICES?
WHICH OF THE FOLLOWING BEST DESCRIBES YOUR MAIN ACTIVITY?
DID YOUR EDUCATION CONTINUE AFTER THE MINIMUM SCHOOL LEAVING AGE?
DO YOU HAVE A DEGREE OR EQUIVALENT PROFESSIONAL QUALIFICATION?

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