Description:

GOG-0263: Quality of Life Questionnaire 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=7170934C-5F81-20E2-E040-BB89AD434964

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7170934C-5F81-20E2-E040-BB89AD434964

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Versions (3) ▾
  1. 8/27/12
  2. 8/11/14
  3. 1/9/15
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 - GOG-0263: Quality of Life Questionnaire - 2933853v1.0

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
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 bothered by discharge or bleeding from my vagina
I am bothered by odor coming from my vagina
I am afraid to have sex
I feel sexually attractive.
My vagina feels too narrow or short
I have concerns about my ability to have children
I am afraid the treatment may harm my body
I am interested in sex
I like the appearance of my body
I am bothered by constipation
I have a good appetite
I have trouble controlling my urine
It burns when I urinate
I have discomfort when I urinate
I am able to eat the foods that I like
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
I urinate more frequently than usual
I have control of my bowels
I have cramps in my stomach area
I have diarrhea
Please rate your pain by selecting the one number that best describes your pain at its WORST in the past 24 hours.
To Be Completed By Clinical Staff
Status of the QOL assessment

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