Description:

PACCT-1 TAILORx FACT - General Form Hormone Therapy With or Without Combination Chemotherapy in Treating Women Who Have Undergone Surgery for Node-Negative Breast Cancer (The TAILORx Trial) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=84B142E1-7E5A-582E-E040-BB89AD436C2E

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=84B142E1-7E5A-582E-E040-BB89AD436C2E

Keywords:
Versions (2) ▾
  1. 8/26/12
  2. 1/8/15
Uploaded on:

January 8, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00310180 Quality of Life - PACCT-1 TAILORx FACT - General Form - 3071611v1.0

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
Report Period (since start of Step 2 Choose one)
Unnamed2
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
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

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