Description:

Gynecologic Oncology Group Smoking History Questionnaire (Form SHQ) Radiation Therapy With or Without Chemotherapy in Patients With Stage I or Stage II Cervical Cancer Who Previously Underwent Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=572CCDFB-3AD6-1370-E044-0003BA3F9857

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=572CCDFB-3AD6-1370-E044-0003BA3F9857
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  1. 8/27/12 8/27/12 -
  2. 8/11/14 8/11/14 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
Uploaded on:

January 9, 2015

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Creative Commons BY-NC 3.0 Legacy
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Cervical Cancer NCT01101451 Quality of Life - Gynecologic Oncology Group Smoking History Questionnaire (Form SHQ) - 2785914v1.0

No Instruction available.

  1. StudyEvent: Gynecologic Oncology Group Smoking History Questionnaire (Form SHQ)
    1. No Instruction available.
Header Module
Smoking History Questionnaire
Have you ever smoked tobacco products?
Personal Smoking Section
Have you smoked at least 100 cigarette during your lifetime
Are you currently using nicotine skin patches or gum
Are you still smoking at least one cigarette per week
Household Smoking Section
Have you ever lived for at least a year in the same household with someone who smoked cigarettes regularly
Do you now live in the same household with someone who smokes cigarettes regularly
Second Hand Smoking Section
Are you exposed to smoke from another person's cigarettes at least once per week when you are outside of your household
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