NSABP Protocol B-36 Quality of Life Questionnaire (English Version) Comparison of Two Combination Chemotherapy Regimens in Treating Women With Breast Cancer NCT00087178 Source Form: NCI FormBuilder:

  1. 8/7/14 8/7/14 - Martin Dugas
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 3/20/15 3/20/15 - Martin Dugas
  4. 4/10/21 4/10/21 - Ahmed Rafee, MD
  5. 9/20/21 9/20/21 -
Copyright Holder:
Uploaded on:

September 20, 2021

To request one please log in.
License :
Creative Commons BY 4.0
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Breast Cancer Chemotherapy (NCT00087178)

No Instruction available.

  1. StudyEvent: NSABP Protocol B-36 Quality of Life Questionnaire (English Version)
    1. No Instruction available.
Time point
This form is being filled out
Quality of life
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.
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)
If you prefer not to answer it, please check this box and go to the next section. (Regardless of your current level of sexual activity, please answer the following question.)
I am satisfied with my sex life.
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.
I am able to work. (include work at home)
My work is fulfilling. (include work at home)
I am able to enjoy life.
I have accepted my illness.
I am sleeping well.
I am enjoying the things I usually do.
I am content with the quality of my life right now.
I have been short of breath.
I am self-conscious about the way I dress.
One or both of my arms are swollen or tender.
I feel sexually attractive.
I am bothered by hair loss.
I worry that other members of my family might someday get the same illness I have.
I worry about the effect of stress on my illness.
I am bothered by a change in weight.
I am able to feel like a woman.
passing a lot of gas (flatulence)
mouth sores
skin problems (including rash, dry skin, itching, irritation or redness)
numbness or tingling in hands or feet
fever or shivering (shaking, chills)
difficulty with bladder control
hot flashes
genital itching or irritation
mood swings
vaginal discharge
vaginal bleeding or spotting
vaginal dryness
pain with intercourse
general aches and pains
joint pains
swelling of hands
muscle stiffness
weight gain
weight loss
unhappy with appearance of my body
night sweats
cold sweats
difficulty concentrating
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
Lifting or carrying groceries
Climbing several flights of stairs
Bending, kneeling, or stooping
Walking more than a mile
Walking several hundred yards
Walking one hundred yards
Bathing or dressing yourself
Did you feel full of life?
Did you have a lot of energy?
Did you feel worn out?
Did you feel tired?
Please score your overall quality of life as of today on an 11-point scale where 0 indicates being in the worst possible health and 10 indicates being in perfect health.

Similar models

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial