Description:

E2906 Quality of Life Assessment Form - FACT Clofarabine or Daunorubicin Hydrochloride and Cytarabine Followed By Decitabine or Observation in Treating Older Patients With Newly Diagnosed Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7586A704-3004-A522-E040-BB89AD4359F8

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7586A704-3004-A522-E040-BB89AD4359F8
Keywords:
  1. 9/19/12 9/19/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
Uploaded on:

January 8, 2015

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Creative Commons BY-NC 3.0 Legacy
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Leukemia NCT01041703 Quality of Life - E2906 Quality of Life Assessment Form - FACT - 2952035v1.0

INSTRUCTIONS: Please complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center. Keep a copy for your files

Header
On Treatment
On Treatment Report Period (Choose one)
Header
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
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
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 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 feel isolated from others because of my illness or treatment
Additional Concerns
I am bothered by fevers (episodes of high body temperature)
I have certain parts of my body where I experience pain
I am bothered by the chills
I have night sweats
I am bothered by lumps or swelling in certain parts of my body (e.g., neck, armpits, or groin)
I bleed easily
I bruise easily
I feel fatigued
I am losing weight
I have a good appetite
I am able to do my usual activities
I worry about getting infections
I feel uncertain about my future health
I worry that I might get new symptoms of my illness
I have emotional ups and downs
I feel isolated from others because of my illness or treatment
Additional Concerns
I feel weak all over
I feel listless ("washed out")
I feel tired
I have trouble starting things because I am tired
I have trouble finishing things because I am tired
I have energy
I feel fatigued
I need to sleep during the day
I am too tired to eat
I am able to do my usual activities
I need help doing my usual activities
I am frustrated by being too tired to do the things I want to do
I have to limit my social activity because I am tired

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