Description:

USMCI 8214/Z6091: SF-36 Patient Self Assessment Questionnaire Standard Therapy With or Without Surgery and Mitomycin C in Treating Patients With Advanced Limited Peritoneal Dissemination of Colon Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=665C50CD-E1EF-DFF5-E040-BB89AD43117E

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=665C50CD-E1EF-DFF5-E040-BB89AD43117E

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Versions (2) ▾
  1. 8/27/12
  2. 1/9/15
Uploaded on:

January 9, 2015

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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Colorectal Cancer NCT01167725 Quality of Life - USMCI 8214/Z6091: SF-36 Patient Self Assessment Questionnaire - 2858927v1.0

No Instruction available.

  1. StudyEvent: USMCI 8214/Z6091: SF-36 Patient Self Assessment Questionnaire
    1. No Instruction available.
Header Module
Header Module
Header
In general, would you say your health is
Compared to one year ago, how would you rate your health in general now
Module Question 3
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
Lifting or carrying groceries
Climbing several flights of stairs
Climbing one flight of stairs
Bending, kneeling or stooping
Walking more than a mile
Walking several blocks
Walking one block
Bathing or dressing yourself
Module Question 4
Cut down on the amount of time you spent on work or other activities (During the past week have you experienced any of the following problems with your work or other regular daily activities as a result of any emotional problems)
Accomplished less than you would like
Were limited in the kind of work or other activities
Had difficulty performing the work or other activities (for example, it took extra effort)
Module Question 5
During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups
Cut down on the amount of time you spent on work or other activities (During the past week have you experienced any of the following problems with your work or other regular daily activities as a result of any emotional problems)
Accomplished less than you would like
Didn't do work or other activities as carefully as usual
How much bodily pain have you had during the past 4 weeks
During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)
Module Question 9
Did you feel full of pep
Have you been a nervous person
Have you felt so down in the dumps nothing could cheer you up
Have you felt calm and peaceful
Did you have a lot of energy
Have you felt downhearted and blue
Did you feel worn out
Have you been a happy person
Did you feel tired
During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)
Module Question 11
I seem to be sick a little easier than other people
I am as healthy as anybody I know
I expect my health to get worse
My health is excellent
Unnamed3
Ability to do sports
Ability to do work
Social activities
Ability do to household chores
Unnamed2
If you had to live with the current symptoms of your affected extremity for the rest of your life, how satisfied would you be
Footer Module

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