Quality of Life Module for Trial 24-02 (Form 24-QLM) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder:

  1. 12/15/14 12/15/14 - Martin Dugas
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December 15, 2014

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Breast Cancer NCT00659373 Quality of Life - Quality of Life Module for Trial 24-02 (Form 24-QLM) - 2073726v3.0

QUALITY OF LIFE MODULE FOR TRIAL 24-02 (Form 24-QLM) Patient Instructions: We would like to know how strongly you are affected by your illness and treatment. Please answer the following questions by placing a vertical mark on the line depending on how you assess yourself. (See the example on the Quality of Life Core Questionnaire.) Your information will be treated as strictly confidential. Thank you for replying!

Within The Last Two Weeks, How Severe Have The Following Problems Been?
Being irritable
Sweats (including night sweats including night)
Vaginal discharge
Vaginal dryness
Vaginal itching / irritation
Sleep disturbance
Feeling dizzy
Bone or joint pain
Troubled by weight gain
Loss of sexual interest
Overall, how much are you bothered by any treatment related difficulties?
Have you been sexually active during the past six months?
Did you have difficulties in becoming aroused?
Ccrr Module For Quality Of Life Module For Trial 24-02 (form 24-qlm)

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