Description:

RTOG 1010 FACT-E Form (Version 4) and Cover Sheet (FA) Radiation Therapy, Paclitaxel, and Carboplatin With or Without Trastuzumab in Treating Patients With Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8666F883-A510-1716-E040-BB89AD436FC4

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8666F883-A510-1716-E040-BB89AD436FC4

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Versions (3) ▾
  1. 8/26/12
  2. 1/9/15
  3. 1/9/15
Uploaded on:

January 9, 2015

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Creative Commons BY-NC 3.0 Legacy
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Adenocarcinoma of the Gastroesophageal Junction NCT01196390 Quality of Life - RTOG 1010 FACT-E Form (Version 4) and Cover Sheet (FA) - 3085308v1.0

INSTRUCTIONS: This page must be completed by the medical staff( nurse, data manager, physician, etc.) Questionnaires for all time points are required even if submission time points deviate from the specified intervals. Only patient death or documented patient refusal will be an acceptable reason for omission of the QOL questionnaires. However, this page must be completed and submitted for every time point on the calendar regardless of whether the QOL questionnaire was completed. Every effort possible should be made to collect the data on time

Header
Amended Data
Unnamed 1
Time point
Was patient questionnaire completed
Reason Questionnaire was not Completed (PATIENT)
Specify method of completion
Did the patient require any assistance in completing the questionnaire?
Specify the person who assisted the patient
Extent of the assistance
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 able to eat the foods that I like
My mouth is dry
I have trouble breathing
My voice has its usual quality and strength
I am able to eat as much food as I want
I am able to communicate with others
I can swallow naturally and easily
I have difficulty swallowing solid foods
I have difficulty swallowing soft or mashed foods
I have difficulty swallowing liquids
I have pain in my chest when I swallow
I choke when I swallow
I am able to enjoy meals with family or friends
I have a good appetite
I wake at night because of coughing
I have pain in my stomach area
I am losing weight