GOG-0258 Quality of Life Survey Form Carboplatin and Paclitaxel With or Without Cisplatin and Radiation Therapy in Treating Patients With Stage I, Stage II, Stage III, or Stage IVA Endometrial Cancer Source Form: NCI FormBuilder:

  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
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January 9, 2015

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Creative Commons BY-NC 3.0 Legacy
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Endometrial Cancer NCT00942357 Quality of Life - GOG-0258 Quality of Life Survey Form - 2844576v1.0

Below is a list of statements that other people with your illness have said are important. By circling one (1) number per line, please indicate how true each statement has been for you during the past 7 days

Header Module
Scheduled time to obtain Quality of Life Questionnaire
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
Functional Wellbeing
I am able to work (include work at home)
My work (include work at home) is fulfilling
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 have swelling in my stomach area
I have cramps in my stomach area
I have discomfort or pain in my stomach area
I have vaginal bleeding or spotting
I have vaginal discharge
I am unhappy about a change in my appearance
I have hot flashes
I have cold sweats
I have night sweats
I feel fatigued
I have pain or discomfort with intercourse
I have trouble digesting food
I have been short of breath
I am bothered by constipation
I urinate more frequently than usual
I have discomfort or pain in my pelvic area
I have control of my bowels
I have diarrhea
Ntx4 Subscale
I have numbness or tingling in my hands
I have numbness or tingling in my feet
I feel discomfort in my hands
I feel discomfort in my feet
To Be Completed By Clinical Staff
Status of the QOL assessment

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