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Total # of Questions: 283

Functional Assessment of Chronic Illness Therapy (FACIT) - Treatment Specific Measures Panel [70672-1]

Date Done

Time Done

Where Done

Comment

Name

Value

Units

Treatment for bone disease expectations [70571-5]

I believe that treatment for bone disease will take up my time [70572-3]

I believe that my treatment for bone disease will take up my family's time [70573-1]

I worry about side effects from treatment for bone disease [70574-9]

I believe that my treatment for bone disease will cause me physical pain [70575-6]

I believe that receiving treatment for bone disease will be inconvenient [70576-4]

I worry that my treatment for bone disease will not be effective [70577-2]

I believe that treatment for bone disease will be harmful to me [70578-0]

I believe that my treatment schedule for bone disease will be stressful to me [70579-8]

I believe that my treatment schedule for bone disease will be stressful to my family [70580-6]

I believe that I will be bothered by side effects of treatment for bone disease [70581-4]

I believe that waiting up to 60M before eating breakfast in the morning will be inconvenient [70582-2]

I believe that an infusion for my bone treatment will cause me physical pain [70583-0]

I believe that having my blood drawn will be inconvenient [70584-8]

Functional assessment of cancer therapy for patients receiving enteral feeding questionnaire - version 1 [70585-5]

I experience a pleasant feeling of fullness during or after my tube feeding [70586-3]

I feel uncomfortably full during or after my tube feeding [70587-1]

I have constipation during or after my tube feeding [70588-9]

I experience vomiting during or after my tube feeding [70589-7]

Tube feeding limits what I can do inside the house (for example housework, watching TV or reading) [70590-5]

Tube feeding limits what I can do outside of the house (for example shopping, driving or yard work) [70591-3]

Tube feeding limits my activities with my friends [70592-1]

During the use of tube feeding, I can eat and drink by mouth [70593-9]

I miss being able to take more food or drink by mouth now that I have a feeding tube [70594-7]

I have the desire to eat [70595-4]

I worry that having a feeding tube means my health is worse [70596-2]

I worry about the tube coming out by accident [70597-0]

I worry about the tube getting plugged or blocked [70598-8]

I worry about getting an infection from the feeding tube [70599-6]

I worry about losing weight because I have a feeding tube [70600-2]

I feel that I have lost control of my food choices because I have a feeding tube [70601-0]

I feel dependent on others because I have a feeding tube [70602-8]

I feel left out when others are eating [70603-6]

I am more confident about my nutrition because of my feeding tube [70604-4]

Getting a feeding tube was the right decision for me [70605-1]

Functional assessment of cancer therapy for patients with EGFRI inhibitors questionnaire - 18 items [70606-9]

My skin or scalp feels irritated [70607-7]

My skin or scalp is dry or "flaky" [70608-5]

My skin or scalp itches [70609-3]

My skin bleeds easily [70610-1]

I am bothered by a change in my skins sensitivity to the sun [70611-9]

My skin condition interferes with my ability to sleep [70612-7]

My skin condition affects my mood [70613-5]

My skin condition interferes with my social life [70614-3]

I am embarrassed by my skin condition [70615-0]

I avoid going out in public because of how my skin looks [70616-8]

I feel unattractive because of how my skin looks [70617-6]

Changes in my skin condition make daily life difficult [70618-4]

The skin side effects from treatment have interfered with household tasks [70619-2]

My eyes are dry [70620-0]

I am bothered by sensitivity around my fingernails or toenails [70621-8]

Sensitivity around my fingernails makes it difficult to perform household tasks [70622-6]

I am bothered by hair loss [70309-0]

I am bothered by increased facial hair [70623-4]

Functional assessment of cancer therapy for patients with neurotoxicity questionnaire - version 4 [70624-2]

Physical well being [70498-1]

I have a lack of energy [70405-6]

I have nausea [70406-4]

Because of my physical condition, I have trouble meeting the needs of my family [70407-2]

I have pain [70408-0]

I am bothered by side effects of treatment [70409-8]

I feel ill [70410-6]

I am forced to spend time in bed [70411-4]

Social - family well being [70499-9]

I feel close to my friends [70412-2]

I get emotional support from my family [70413-0]

I get support from my friends [70414-8]

My family has accepted my illness [70415-5]

I am satisfied with family communication about my illness [70416-3]

I felt close to my partner, or the person who is my main support [70417-1]

Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please mark this box and go to the next section. [70914-7]

I am satisfied with my sex life [70418-9]

Emotional well being [70500-4]

I feel sad [70392-6]

I am satisfied with how I am coping with my illness [70393-4]

I am losing hope in the fight against my illness [70394-2]

I am nervous [70395-9]

I worry about dying [70396-7]

I worry that my condition will get worse [70397-5]

Functional well being [70501-2]

I am able to work (include work at home) [70398-3]

My work (include work at home) is fulfilling [70399-1]

I am able to enjoy life [70400-7]

I have accepted my illness [70401-5]

I am sleeping well [70402-3]

I am enjoying the things I usually do for fun [70403-1]

I am content with the quality of my life right now [70404-9]

Additional concerns - FACT-GOG-NTX [70887-5]

I have numbness or tingling in my hands [70562-4]

I have numbness or tingling in my feet [70625-9]

I feel discomfort in my hands [70626-7]

I feel discomfort in my feet [70627-5]

I have joint pain or muscle cramps [70628-3]

I feel weak all over [70425-4]

I have trouble hearing [70477-5]

I get a ringing or buzzing in my ears [70629-1]

I have trouble buttoning buttons [70630-9]

I have trouble feeling the shape of small objects when they are in my hand [70631-7]

I have trouble walking [70632-5]

Functional assessment of cancer therapy for patients with neurotoxicity questionnaire - 12 items - version 4 [70633-3]

Physical well being [70498-1]

I have a lack of energy [70405-6]

I have nausea [70406-4]

Because of my physical condition, I have trouble meeting the needs of my family [70407-2]

I have pain [70408-0]

I am bothered by side effects of treatment [70409-8]

I feel ill [70410-6]

I am forced to spend time in bed [70411-4]

Social - family well being [70499-9]

I feel close to my friends [70412-2]

I get emotional support from my family [70413-0]

I get support from my friends [70414-8]

My family has accepted my illness [70415-5]

I am satisfied with family communication about my illness [70416-3]

I felt close to my partner, or the person who is my main support [70417-1]

Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please mark this box and go to the next section. [70914-7]

I am satisfied with my sex life [70418-9]

Emotional well being [70500-4]

I feel sad [70392-6]

I am satisfied with how I am coping with my illness [70393-4]

I am losing hope in the fight against my illness [70394-2]

I am nervous [70395-9]

I worry about dying [70396-7]

I worry that my condition will get worse [70397-5]

Functional well being [70501-2]

I am able to work (include work at home) [70398-3]

My work (include work at home) is fulfilling [70399-1]

I am able to enjoy life [70400-7]

I have accepted my illness [70401-5]

I am sleeping well [70402-3]

I am enjoying the things I usually do for fun [70403-1]

I am content with the quality of my life right now [70404-9]

Additional concerns - FACT-GOG-NTX-12 [70888-3]

I have numbness or tingling in my hands [70562-4]

I have numbness or tingling in my feet [70625-9]

I feel discomfort in my hands [70626-7]

I feel discomfort in my feet [70627-5]

I have joint pain or muscle cramps [70628-3]

I feel weak all over [70425-4]

I have trouble hearing [70477-5]

I get a ringing or buzzing in my ears [70629-1]

I have trouble buttoning buttons [70630-9]

I have trouble feeling the shape of small objects when they are in my hand [70631-7]

I have trouble walking [70632-5]

I have pain in my hands or feet when I am exposed to cold temperatures [70563-2]

Functional assessment of cancer therapy for patients with neurotoxicity questionnaire - 13 items - version 4 [70635-8]

Physical well being [70498-1]

I have a lack of energy [70405-6]

I have nausea [70406-4]

Because of my physical condition, I have trouble meeting the needs of my family [70407-2]

I have pain [70408-0]

I am bothered by side effects of treatment [70409-8]

I feel ill [70410-6]

I am forced to spend time in bed [70411-4]

Social - family well being [70499-9]

I feel close to my friends [70412-2]

I get emotional support from my family [70413-0]

I get support from my friends [70414-8]

My family has accepted my illness [70415-5]

I am satisfied with family communication about my illness [70416-3]

I felt close to my partner, or the person who is my main support [70417-1]

Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please mark this box and go to the next section. [70914-7]

I am satisfied with my sex life [70418-9]

Emotional well being [70500-4]

I feel sad [70392-6]

I am satisfied with how I am coping with my illness [70393-4]

I am losing hope in the fight against my illness [70394-2]

I am nervous [70395-9]

I worry about dying [70396-7]

I worry that my condition will get worse [70397-5]

Functional well being [70501-2]

I am able to work (include work at home) [70398-3]

My work (include work at home) is fulfilling [70399-1]

I am able to enjoy life [70400-7]

I have accepted my illness [70401-5]

I am sleeping well [70402-3]

I am enjoying the things I usually do for fun [70403-1]

I am content with the quality of my life right now [70404-9]

Additional concerns - FACT-GOG-NTX-13 [70889-1]

I have numbness or tingling in my hands [70562-4]

I have numbness or tingling in my feet [70625-9]

I feel discomfort in my hands [70626-7]

I feel discomfort in my feet [70627-5]

I have joint pain or muscle cramps [70628-3]

I feel weak all over [70425-4]

I have trouble hearing [70477-5]

I get a ringing or buzzing in my ears [70629-1]

I have trouble buttoning buttons [70630-9]

I have trouble feeling the shape of small objects when they are in my hand [70631-7]

I have trouble walking [70632-5]

I have pain in my hands or feet when I am exposed to cold temperatures [70563-2]

I have difficulty breathing when I am exposed to cold temperatures [70634-1]

Functional assessment of cancer therapy for patients with neurotoxicity questionnaire - 4 items - version 4 [70636-6]

I have numbness or tingling in my hands [70562-4]

I have numbness or tingling in my feet [70625-9]

I feel discomfort in my hands [70626-7]

I feel discomfort in my feet [70627-5]

Functional assessment of cancer therapy for patients undergoing bone marrow transplantation questionnaire - version 4 [70637-4]

Physical well being [70498-1]

I have a lack of energy [70405-6]

I have nausea [70406-4]

Because of my physical condition, I have trouble meeting the needs of my family [70407-2]

I have pain [70408-0]

I am bothered by side effects of treatment [70409-8]

I feel ill [70410-6]

I am forced to spend time in bed [70411-4]

Social - family well being [70499-9]

I feel close to my friends [70412-2]

I get emotional support from my family [70413-0]

I get support from my friends [70414-8]

My family has accepted my illness [70415-5]

I am satisfied with family communication about my illness [70416-3]

I felt close to my partner, or the person who is my main support [70417-1]

Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please mark this box and go to the next section. [70914-7]

I am satisfied with my sex life [70418-9]

Emotional well being [70500-4]

I feel sad [70392-6]

I am satisfied with how I am coping with my illness [70393-4]

I am losing hope in the fight against my illness [70394-2]

I am nervous [70395-9]

I worry about dying [70396-7]

I worry that my condition will get worse [70397-5]

Functional well being [70501-2]

I am able to work (include work at home) [70398-3]

My work (include work at home) is fulfilling [70399-1]

I am able to enjoy life [70400-7]

I have accepted my illness [70401-5]

I am sleeping well [70402-3]

I am enjoying the things I usually do for fun [70403-1]

I am content with the quality of my life right now [70404-9]

Additional concerns - FACT-BMT [70890-9]

I am concerned about keeping my job (include work at home) [70638-2]

I feel distant from other people [70639-0]

I worry that the transplant will not work [70640-8]

The effects of treatment are worse than I had imagined [70641-6]

I have a good appetite [70350-4]

I like the appearance of my body [70351-2]

I am able to get around by myself [70320-7]

I get tired easily [70528-5]

I am interested in sex [70317-3]

I have concerns about my ability to have children [70321-5]

I have confidence in my nurse(s) [70642-4]

I regret having the bone marrow transplant [70643-2]

I can remember things [70663-0]

I am able to concentrate [70323-1]

I have frequent colds/infections [70644-0]

My eyesight is blurry [70645-7]

I am bothered by a change in the way food tastes [70668-9]

I have tremors [70646-5]

I have been short of breath [70305-8]

I am bothered by skin problems [70565-7]

I have trouble with my bowels [70669-7]

My illness is a personal hardship for my close family members [70647-3]

The cost of my treatment is a burden on me or my family [70648-1]

Functional assessment of cancer therapy for patients receiving biologic response modifiers questionnaire - version 4 [70649-9]

Physical well being [70498-1]

I have a lack of energy [70405-6]

I have nausea [70406-4]

Because of my physical condition, I have trouble meeting the needs of my family [70407-2]

I have pain [70408-0]

I am bothered by side effects of treatment [70409-8]

I feel ill [70410-6]

I am forced to spend time in bed [70411-4]

Social - family well being [70499-9]

I feel close to my friends [70412-2]

I get emotional support from my family [70413-0]

I get support from my friends [70414-8]

My family has accepted my illness [70415-5]

I am satisfied with family communication about my illness [70416-3]

I felt close to my partner, or the person who is my main support [70417-1]

Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please mark this box and go to the next section. [70914-7]

I am satisfied with my sex life [70418-9]

Emotional well being [70500-4]

I feel sad [70392-6]

I am satisfied with how I am coping with my illness [70393-4]

I am losing hope in the fight against my illness [70394-2]

I am nervous [70395-9]

I worry about dying [70396-7]

I worry that my condition will get worse [70397-5]

Functional well being [70501-2]

I am able to work (include work at home) [70398-3]

My work (include work at home) is fulfilling [70399-1]

I am able to enjoy life [70400-7]

I have accepted my illness [70401-5]

I am sleeping well [70402-3]

I am enjoying the things I usually do for fun [70403-1]

I am content with the quality of my life right now [70404-9]

Additional concerns - physical [70912-1]

I get tired easily [70528-5]

I feel weak all over [70425-4]

I have a good appetite [70350-4]

I have pain in my joints [70670-5]

I am bothered by the chills [70527-7]

I am bothered by fevers (episodes of high body temperature) [70344-7]

I am bothered by sweating [70650-7]

Additional concerns - mental [70913-9]

I have trouble concentrating [70530-1]

I have trouble remembering things [70651-5]

I get depressed easily [70652-3]

I get annoyed easily [70653-1]

I have emotional ups and downs [70319-9]

I feel motivated to do things [70654-9]

Functional assessment of cancer therapy - taxane questionnaire - version 4 [70655-6]

I have numbness or tingling in my hands [70562-4]

I have numbness or tingling in my feet [70625-9]

I feel discomfort in my hands [70626-7]

I feel discomfort in my feet [70627-5]

I have joint pain or muscle cramps [70628-3]

I feel weak all over [70425-4]

I have trouble hearing [70477-5]

I get a ringing or buzzing in my ears [70629-1]

I have trouble buttoning buttons [70630-9]

I have trouble feeling the shape of small objects when they are in my hand [70631-7]

I have trouble walking [70632-5]

I feel bloated [70656-4]

My hands are swollen [70657-2]

My legs or feet are swollen [70658-0]

I have pain in my fingertips [70659-8]

I am bothered by the way my hands or nails look [70660-6]

PLEASE WAIT