Description:

NSABP Protocol C-09: Quality of Life Form Oxaliplatin and Capecitabine With or Without an Hepatic Arterial Infusion With Floxuridine in Treating Patients Who Are Undergoing Surgery and/or Ablation for Liver Metastases Due to Colorectal Cancer NCT00268463 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FC7E0FCB-064A-58CD-E034-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FC7E0FCB-064A-58CD-E034-0003BA3F9857

Keywords:
Versions (5) ▾
  1. 8/27/12
  2. 1/9/15
  3. 3/21/15
  4. 4/10/21
  5. 9/20/21
Copyright Holder:
folgt
Uploaded on:

September 20, 2021

DOI:
No DOI assigned. 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.

Back to model comments
Itemgroup comments for:

Item comments for:

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

Colorectal cancer metastases (NCT00268463)

Details

All patients in C-09 should complete this questionnaire at: (1) baseline (after consent and prior to randomization) and (2) 4-6 weeks after surgery

Header
Are data amended (check box if yes, and circle amended items)
This form is being filled out
Time Point
Does the patient have a hepatic pump
indicate location of hepatic pump
Treatment satisfaction
Receiving treatment is convenient for me
I am satisfied with my current treatment
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)
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 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 for fun
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 can digest my food well
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
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
I have joint pain or muscle cramps
I feel weak all over
I have trouble hearing
I get a ringing or buzzing in my ears
I have trouble buttoning buttons
I have trouble feeling the shape of small objects when they are in my hand
I have trouble walking
I have pain in my hands or feet when I am exposed to cold temperatures
I have difficulty breathing when I am exposed to cold temperatures
Abdominal pain or cramping
Gas pain
Mouth sores
Vomiting
Skin problems (including rash, dry skin, itching, irritation or redness)
Skin redness or peeling on hands and feet
Hair loss
Pain at intravenous site
Eye problems
Other problems (Specify below)
How self conscious have you felt about your body and your appearance
7 more items in the detailed view.
How satisfied have you been with the way your chemotherapy is being delivered
7 more items in the detailed view.
How much have you feared that your pump will be dislodged
7 more items in the detailed view.
How much discomfort or pain has your pump caused you
7 more items in the detailed view.
How much have you protected your body where the pump is located
7 more items in the detailed view.
Activity
Did you feel full of life
Did you have a lot of energy
Did you feel worn out
Did you feel tired
Your ability to do vigorous activities
7 more items in the detailed view.
The position you like to sleep in
7 more items in the detailed view.
Your ability to eat a full meal
7 more items in the detailed view.
Your ability to lift things
7 more items in the detailed view.
Hugging family or friends
7 more items in the detailed view.
Bending over or twisting
7 more items in the detailed view.
Your ability to travel
7 more items in the detailed view.
The type of clothing you wear
7 more items in the detailed view.
Your comfort in sexual activities
7 more items in the detailed view.
Back to the top of the page 

Similar models