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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:

Colorectal Neoplasms

Clinical Trial

Quality of Life

Versions (5)

8/27/12 8/27/12 -
1/9/15 1/9/15 - Martin Dugas
3/21/15 3/21/15 - Martin Dugas
4/10/21 4/10/21 - Ahmed Rafee, MD
9/20/21 9/20/21 -

Copyright Holder:

folgt

Uploaded on:

September 20, 2021

DOI:

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License :

Creative Commons BY 4.0

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Colorectal cancer metastases (NCT00268463)

English 1

English

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

1 forms

StudyEvent: NSABP Protocol C-09: Quality of Life Form
1. 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

Patient Initials (Last First Middle)

NSABP Patient ID

Institution Name

Affiliate Name

Staff Member Administering Form Last Name

Staff Member Administering Form First Name

Staff Member Administering Form Phone

Are data amended (check box if yes, and circle amended items)

Yes

This form is being filled out

By participant in doctor's office/clinic (By participant in doctor's office/clinic)

By participant not in doctor's office/clinic (By participant not in doctor's office/clinic)

By clinical staff, on phone with participant (By clinical staff, on phone with participant)

Other (Other)

Time Point

Baseline (Baseline)

18 Weeks (18 weeks)

4-6 Weeks After Surgery (4-6 weeks after surgery)

Post-chemotherapy (Post chemotherapy)

Does the patient have a hepatic pump

Yes

indicate location of hepatic pump

Lower chest (Lower chest)

Abdomen (Abdomen)

Date this questionnaiare is completed (Month Day Year)

Treatment satisfaction

Receiving treatment is convenient for me

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have not received treatment in the past month (6)

I am satisfied with my current treatment

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have not received treatment in the past month (6)

Physical Well-being

I have a lack of energy

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have nausea

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

Because of my physical condition, I have trouble meeting the needs of my family

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have pain

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I am bothered by side effects of treatment

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I feel ill

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I am forced to spend time in bed

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

Social/family Well-being

I feel close to my friends

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I get emotional support from my family

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I get support from my friends

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

My family has accepted my illness

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I am satisfied with family communication about my illness

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I feel close to my partner (or the person who is my main support)

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I am satisfied with my sex life

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

Emotional Well-being

I feel sad

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I am satisfied with how I am coping with my illness

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I am losing hope in the fight against my illness

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I feel nervous

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I worry about dying

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I worry that my condition will get worse

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

Functional Well-being

I am able to work (include work at home)

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

My work is fulfilling (include work at home)

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I am able to enjoy life

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have accepted my illness

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I am sleeping well

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I am enjoying the things I usually do for fun

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I am content with the quality of my life right now

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

Additional Concerns

I have swelling or cramps in my stomach area

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I am losing weight

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have control of my bowels

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I can digest my food well

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have diarrhea

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have a good appetite

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I like the appearance of my body

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

Do you have an ostomy appliance

Yes

I am embarrassed by my ostomy appliance

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

Caring for my ostomy appliance is difficult

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have numbness or tingling in my hands

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have numbness or tingling in my feet

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I feel discomfort in my hands

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I feel discomfort in my feet

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have joint pain or muscle cramps

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I feel weak all over

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have trouble hearing

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I get a ringing or buzzing in my ears

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have trouble buttoning buttons

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have trouble feeling the shape of small objects when they are in my hand

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have trouble walking

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have pain in my hands or feet when I am exposed to cold temperatures

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

I have difficulty breathing when I am exposed to cold temperatures

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

Abdominal pain or cramping

Not bothered at all (1)

Bothered a little (2)

Bothered somewhat (3)

Quite bothered (4)

Very bothered (5)

Gas pain

Not bothered at all (1)

Bothered a little (2)

Bothered somewhat (3)

Quite bothered (4)

Very bothered (5)

Mouth sores

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

Vomiting

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

Skin problems (including rash, dry skin, itching, irritation or redness)

Not bothered at all (1)

Bothered a little (2)

Bothered somewhat (3)

Quite bothered (4)

Very bothered (5)

Skin redness or peeling on hands and feet

Not bothered at all (1)

Bothered a little (2)

Bothered somewhat (3)

Quite bothered (4)

Very bothered (5)

Hair loss

Not bothered at all (1)

Bothered a little (2)

Bothered somewhat (3)

Quite bothered (4)

Very bothered (5)

Pain at intravenous site

Not bothered at all (1)

Bothered a little (2)

Bothered somewhat (3)

Quite bothered (4)

Very bothered (5)

Eye problems

Not at all (1)

A little bit (2)

Somewhat (3)

Quite a bit (4)

Very much (5)

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Description:

Link:

Keywords:

Versions (5)

Copyright Holder:

Uploaded on:

DOI:

License :

Model comments :

Itemgroup comments for :

Item comments for :

Colorectal cancer metastases (NCT00268463)

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

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