Description:

AMC-045 Quality of Life Instruments (QLQ) Phase II Trial Of Combined Modality Therapy Plus Cetuximab in HIV-Associated Anal Carcinoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7288A090-8102-4969-E040-BB89AD433657

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7288A090-8102-4969-E040-BB89AD433657

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  1. 5/9/12
  2. 8/11/14
Uploaded on:

August 11, 2014

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License:
Creative Commons BY-NC 3.0 Legacy
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Anal Cancer NCT00324415 Quality of Life - AMC-045 Quality of Life Instruments (QLQ)_2937315v1_0

No Instruction available.

  1. StudyEvent: AMC-045 Quality of Life Instruments (QLQ)
    1. No Instruction available.
Unnamed1
EORTC QLQ-C30 (version 3)
Do you have any trouble doing strenuous activities, like carrying a heavy shopping bag or a suitcase
Do you have any trouble taking a long walk
Do you have any trouble taking a short walk outside of the house
Do you need to stay in bed or a chair during the day
Do you need help with eating, dressing, washing yourself or using the toilet
Eortc1
Were you limited in doing either your work or other daily activities?
Were you limited in pursuing your hobbies or other leisure time activities?
Were you short of breath
Have you had pain
Did you need to rest
Eortc2
Have you had trouble sleeping
Have you felt weak
Have you lacked appetite
Have you felt nauseated
Have you vomited
Eortc3
Have you been constipated
Have you had diarrhea
Were you tired
Did pain interfere with your daily activities
Have you had difficulty in concentrating on things, like reading a newspaper or watching television
Eortc4
Did you feel tense
Did you worry
Did you feel irritable
Did you feel depressed
Have you had difficulty remembering things
Eortc5
Has your physical condition or medical treatment interfered with your family life
Has your physical condition or medical treatment interfered with your social activities
Has your physical condition or medical treatment caused you financial difficulties
How would you rate your overall health during the past week? (For the following questions please circle the number between 1 and 7 that best applies to you)
How would you rate your overall quality of life during the past week? (For the following questions please circle the number between 1 and 7 that best applies to you)
Additional Concerns
Did you urinate frequently during the day
Did you urinate frequently during the night?
Did you have pain when you urinated?
Did you have a bloated feeling in your abdomen
Did you have abdominal pain?
Did you have pain in your buttocks?
Were you bothered by gas (flatulence)?
Did you belch?
Have you lost weight?
Did you have a dry mouth?
Have you had thin or lifeless hair as a result of your disease or treatment
Did food and drink taste different from usual?
Have you felt physically less attractive as a result of your disease or treatment?
Have you been feeling less feminine/masculine as a result of your disease or treatment?
Have you been dissatisfied with your body?
Were you worried about your health in the future?
During The Past Four Weeks:
To what extent were you interested in sex?
To what extent were you sexually active (with or without intercourse)?
To what extent was sex enjoyable for you? (Answer this question only if you have been sexually active)
Did you have difficulty getting or maintaining an erection? (For men only)
Did you have problems with ejaculation (e.g., so-called 'dry ejaculation')? (For men only)
Did you have a dry vagina during intercourse? (Only for women who have had intercourse)
Did you have pain during intercourse? (Only for women who have had intercourse)
Stoma
Do you have a stoma (colostomy bag)?
Only For Patients Without A Stoma (colostomy Bag):
Did you have frequent bowel movements during the day?
Did you have frequent bowel movements during the night?
Did you feel the urge to move your bowels without actually producing any stools
Have you had any unintentional release of stools
Have you had blood with your stools
Have you had difficulty in moving your bowels
Have your bowel movements been painful?
Unnamed 4
Were you afraid that other people would be able to hear your stoma
Were you afraid that other people would be able to smell your stools
Were you worried about possible leakage from the stoma bag?
Did you have problems with caring for your stoma
Was your skin around the stoma irritated
Did you feel embarassed because of your stoma
Did you feel less complete because of your stoma
Supplemental Quality Of Life Questions
How satisfied are you with your current degree of anal or anal/rectal function (on a scale of 1-10 with 1 being totally dissatisfied to 10 totally satisfied)
How well does your anus function (MEMORIAL SLOAN KETTERING ANAL FUNCTION SCALE)