Description:

NSABP-B-47 Medical Conditions and Lifestyle Questionnaire Form - Baseline (Form MCL-B) A Randomized Phase III Trial of Adjuvant Therapy Comparing Chemotherapy Alone (Six Cycles of Docetaxel Plus Cyclophosphamide or Four Cycles of Doxorubicin Plus Cyclophosphamide Followed by Weekly Paclitaxel) to Chemotherapy Plus Trastuzumab in Women With Node- Positive or High-Risk Node-Negative HER2-Low Invasive Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=96C1751F-BCDC-2B10-E040-BB89AD433A9B

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=96C1751F-BCDC-2B10-E040-BB89AD433A9B

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Versions (5) ▾
  1. 8/27/12
  2. 8/11/14
  3. 8/11/14
  4. 8/11/14
  5. 1/9/15
Uploaded on:

January 9, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT01275677 Quality of Life - NSABP-B-47 Medical Conditions and Lifestyle Questionnaire Form - Baseline (Form MCL-B) - 3165170v1.0

INSTRUCTIONS TO THE INSTITUTION This questionnaire should be completed by all patients. This form should be completed after the patient has signed the B-47 consent forms, but before randomization. A clinical staff member should complete page 1, print the patient's initials at the top of Pages 2 through 5, and give the questionnaire to the patient for completion. After the patient has completed the questionnaire, verify that the date the questionnaire was completed is recorded at the top of page 2. After the patient has been randomized, print the NSABP Patient ID at the top of pages 2 through 5 and fax all 5 pages to the NSABP Biostatistical Center at (412) 622-2115

Header
Are data amended (If yes, check the box and circle amended items)
Time Point
This form is being filled out (mark one)
Section 1 - Lifetime Medical Conditions
Problem
Have you ever seen a doctor for the problem?
Do you currently receive treatment for it?
Does it now limit your activities?
Section 2 - Tobacco Usage
Have you smoked at least 100 cigarettes in your entire life? (100 cigarettes = 5 packs)
Have you used other forms of tobacco regularly
Have you used other forms of tobacco regularly (Check all that apply)
Did you use tobacco (In the past week)
On about how many days did you use tobacco (During the period of your life when you used tobacco, think about a typical month)
On the days you did smoke, what was the average number of cigarettes you smoked per day (Think about a typical month when you smoked cigarettes)
Section 3 - Alcohol Consumption
During your entire life, have you had at least 12 drinks of any kind of alcoholic beverage? ([this includes beer 1 bottle/can, wine 1 glass, and hard liquor 1 cocktail or 1 shot of liquor])
In any one year have you had at least 12 drinks of any kind of alcoholic beverage (this includes beer, wine, and hard liquor)
In the last 12 months have you had at least 12 drinks of any kind of alcoholic beverage (this includes beer, wine, and hard liquor)
On about how many days did you have at least one drink of alcohol (In the last 12 months when you drank alcohol, think about a typical month)
On the days when you drank, about how many drinks did you have on average

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