Description:

E3F05 Quality of Life Assessment Form - FACT-BR Radiation Therapy With or Without Temozolomide in Treating Patients With Low-Grade Glioma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B0EE8BE4-1DEE-C782-E040-BB89AD433D2E

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https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B0EE8BE4-1DEE-C782-E040-BB89AD433D2E

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Versions (2) ▾
  1. 8/26/12
  2. 1/9/15
Uploaded on:

January 9, 2015

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Creative Commons BY-NC 3.0 Legacy
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Brain and Central Nervous System Tumors NCT00978458 Quality of Life - E3F05 Quality of Life Assessment Form - FACT-BR - 3299831v1.0

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 (NOTE: Select the "Progression" timepoint when patient's disease progresses at ANY POINT even if it falls within an annual assessment, eg: 48 Months Post Registaration. Please do not select an annual report period AND the progression report period.)
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
Additional Concerns
I am able to concentrate
I have had seizures (convulsions)
I can remember new things
I get frustrated that I cannot do things I used to
I am afraid of having a seizure (convulsion)
I have trouble with my eyesight
I feel independent
I have trouble hearing
I am able to find the right word(s) to say what I mean
I have difficulty expressing my thoughts
I am bothered by the change in my personality
I am able to make decisions and take responsibility
I am bothered by the drop in my contribution to the family
I am able to put my thoughts together
I need help in caring for myself (bathing, dressing, eating, etc.)
I am able to put my thoughts into action
I am able to read like I used to
I am able to write like I used to
I am able to drive a vehicle (my car, truck, etc.)
I have trouble feeling sensations in my arms, hands, or legs
I have weakness in my arms or legs
I have trouble with coordination
I get headaches