Description:

Quality of Life Core Questionnaire (Form 24-QLC) 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: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B0EA521D-9A9B-6310-E034-0003BA12F5E7

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B0EA521D-9A9B-6310-E034-0003BA12F5E7
Keywords:
  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on:

January 9, 2015

DOI:
To request one please log in.
License :
Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Breast Cancer NCT00659373 Quality of Life - Quality of Life Core Questionnaire (Form 24-QLC) - 2073639v3.0

QUALITY OF LIFE CORE QUESTIONNAIRE (Form 24-QLC) Patient Instructions: We would like to know how strongly you are affected by your illness and treatment. Please answer all of the following questions by placing a vertical mark on the line depending on how you assess yourself. For example: Have you had trouble sleeping? None A lot This mark would indicate considerable sleeping difficulties. Your information will be treated as strictly confidential. Thank you for replying!

How Have You Been Within The Last Two Weeks?
Physical Well-Being
Mood
Tiredness
Appetite
Hot Flushes
Feeling Sick (nausea/vomiting)
How much effort does it cost you to cope with your illness?
Do you feel supported by the people close to you?
Does the operation restrict the use of your arm?
Imagine that you would have to live the rest of your life in your current condition. Please indicate, on the line below, how you would rate a life in your current condition between perfect health and worst health.Make a vertical mark according to your est
Ccrr Module For Quality Of Life Core Questionnaire (form 24-qlc)

Similar models

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial