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Total # of Questions: 312

Functional Assessment of Chronic Illness Therapy (FACIT) - Pediatric Measures Panel [70675-4]

Date Done

Time Done

Where Done

Comment

Name

Value

Units

Pediatric - functional assessment of anorexia cachexia - adolescent questionnaire - version 1 [71142-4]

Physical well being - FACIT-peds [71216-6]

I lose balance or fall down easily [71163-0]

I have trouble getting myself dressed [71164-8]

I have trouble running like other people [71165-5]

I get tired easily [70528-5]

My arms or legs feel weak [71166-3]

I get ill easily [71167-1]

I have trouble writing with a pen or pencil [71168-9]

I have pain [70408-0]

Emotional well being and illness experience - FAACT-peds-adoles [71217-4]

I feel happy [71169-7]

When I try to do something, I usually believe I will do it well [71170-5]

The cancer/tumor experience makes me a stronger person [71171-3]

The cancer/tumor experience has taught me to appreciate life [71172-1]

I often feel that other people are better than me [71173-9]

I worry about getting another cancer/tumor [71174-7]

I often switch from good moods to bad moods [71175-4]

I worry when I go back to the hospital or clinic [71176-2]

I get nervous (frightened) easily [71177-0]

I worry about having a good life in the future [71178-8]

I worry about being able to have a girlfriend or boyfriend because of my illness [71179-6]

I worry about being able to go to college because of my illness [71180-4]

I worry about getting a job because of my illness [71181-2]

Social - family well being - FAACT-peds [71218-2]

Other people pick on (tease) me [71182-0]

I think I have fewer friends than others in the past 7D [71192-9]

Other people avoid hanging out with me because I am in the past 7D [71193-7]

I feel lonely [71185-3]

I would rather do something by myself than with other people in the past 7D [71194-5]

My parents worry too much about me [71187-9]

My parents spoil me [71188-7]

Additional concerns - FAACT-child_adoles [71226-5]

I eat as much as I want [71152-3]

I eat enough food for me to do whatever I need to do [71153-1]

I am worried about my weight [70678-8]

Most food tastes bad to me [71154-9]

I am worried about how thin I am [71189-5]

As soon as I start eating, I feel like stopping [71155-6]

I am afraid to eat because it may make me sick [71156-4]

My family or friends try to get me to eat more [71157-2]

I have been throwing up [71158-0]

When I eat, I seem to get full quickly [70684-6]

I have pain in my stomach [71159-8]

I feel like I am getting better [71160-6]

Please tell us anything else that you think would be important about how you feel about food and eating [71190-3]

Pediatric - functional assessment of anorexia cachexia - child questionnaire - version 1 [71143-2]

Physical well being - FACIT-peds [71216-6]

I lose balance or fall down easily [71163-0]

I have trouble getting myself dressed [71164-8]

I have trouble running like other children [71165-5]

I get tired easily [70528-5]

My arms or legs feel weak [71166-3]

I get ill easily [71167-1]

I have trouble writing with a pen or pencil [71168-9]

I have pain [70408-0]

Emotional well being and illness experience - FAACT-peds-child [71343-8]

I feel happy [71169-7]

When I try to do something, I usually believe I will do it well [71170-5]

The cancer/tumor experience makes me a stronger person [71171-3]

The cancer/tumor experience has taught me to appreciate life [71172-1]

I often feel that other children are better than me [71233-1]

I worry about getting another cancer/tumor [71174-7]

I often switch from good moods to bad moods [71175-4]

I worry when I go back to the hospital or clinic [71176-2]

I get nervous (frightened) easily [71177-0]

I worry about having a good life in the future [71178-8]

I worry about being able to have a girlfriend or boyfriend because of my illness [71179-6]

I worry about being able to go to college because of my illness [71180-4]

I worry about getting a job because of my illness [71181-2]

Social - family well being - FAACT-peds [71218-2]

Other children pick on - tease me in the past 7D [71182-0]

I think I have fewer friends than other children [71192-9]

Other children avoid playing with me because I am different [71193-7]

I feel lonely [71185-3]

I would rather play alone than with other children [71194-5]

My parents worry too much about me [71187-9]

My parents spoil me [71188-7]

Additional concerns - FAACT-child_adoles [71226-5]

I eat as much as I want [71152-3]

I eat enough food for me to do whatever I need to do [71153-1]

I am worried about my weight [70678-8]

Most food tastes bad to me [71154-9]

I am worried about how thin I am [71189-5]

As soon as I start eating, I feel like stopping [71155-6]

I am afraid to eat because it may make me sick [71156-4]

My family or friends try to get me to eat more [71157-2]

I have been throwing up [71158-0]

When I eat, I seem to get full quickly [70684-6]

I have pain in my stomach [71159-8]

I feel like I am getting better [71160-6]

Please tell us anything else that you think would be important about how you feel about food and eating [71190-3]

Pediatric - functional assessment of anorexia cachexia - parent_adolescent questionnaire - version 1 [71144-0]

Physical well being - FAACT-peds - parent [71234-9]

My child loses balance or falls down easily [71265-3]

My child has trouble getting dressed on his-her own [71266-1]

My child has trouble running like other people [71267-9]

My child gets tired [71268-7]

My child's arms or legs seem weak [71269-5]

My child gets ill easily [71270-3]

My child has trouble writing with a pen or pencil [71271-1]

My child has pain [71202-6]

Emotional well being - FAACT-peds - parent_adoles [71235-6]

My child seems happy [71236-4]

When my child tries to do something, s-he usually believes s-he will do it well [71237-2]

The cancer/tumor experience makes my child a stronger person [71205-9]

The cancer-tumor experience has taught my child to appreciate life [71206-7]

My child often feels inferior to other people [71238-0]

My child worries about getting another cancer-tumor [71239-8]

My child is moody or irritable [71240-6]

My child worries when we go back to the hospital or clinic [71241-4]

My child gets nervous - frightened easily [71242-2]

My child worries about having a good life in the future [71243-0]

My child worries about being able to have a girlfriend or boyfriend because of his-her illness [71244-8]

My child worries about being able to go to college because of his-her illness [71245-5]

My child worries about getting a job because of his-her illness [71246-3]

Social - family well being - FAACT-parent_adoles [71264-6]

Other people pick on - tease my child [71272-9]

My child has fewer friends than others [71247-1]

Other people avoid hanging out with my child because s-he is different [71248-9]

My child seems lonely [71249-7]

My child prefers to do something alone [71250-5]

My child thinks I worry too much about him/her [71224-0]

My child thinks I spoil him/her [71225-7]

Additional concerns - FAACT-parent [71251-3]

My child eats as much as s-he wants [71252-1]

My child eats enough to do whatever s-he needs to do [71253-9]

My child is worried about his-her weight [71254-7]

Most food tastes bad to my child [71255-4]

My child is worried about how thin s-he is [71256-2]

As soon as my child starts eating, s-he feels like stopping [71257-0]

My child is afraid to eat because it may make her-him sick [71258-8]

Family or friends try to get my child to eat more [71273-7]

My child has been throwing up [71260-4]

When my child eats, s-he seems to get full quickly [71261-2]

My child has pain in his-her stomach [71262-0]

My child feels like s-he is getting better [71263-8]

Please tell us anything else that you think would be important about how you feel about food and eating [71190-3]

Pediatric - functional assessment of anorexia cachexia - parent_child questionnaire - version 1 [71145-7]

Physical well being - FAACT-peds - parent [71234-9]

My child loses balance or falls down easily [71265-3]

My child has trouble getting dressed on his-her own [71266-1]

My child has trouble running like other children in the past 7D [71267-9]

My child gets tired [71268-7]

My child's arms or legs seem weak [71269-5]

My child gets ill easily [71270-3]

My child has trouble writing with a pen or pencil [71271-1]

My child has pain [71202-6]

Emotional well being - FAACT-peds - parent_child [71274-5]

My child seems happy [71236-4]

When my child tries to do something, s-he usually believes s-he will do it well [71237-2]

The cancer/tumor experience makes my child a stronger person [71205-9]

The cancer-tumor experience has taught my child to appreciate life [71206-7]

My child often feels inferior to other children in the past 7D [71238-0]

My child worries about getting another cancer-tumor [71239-8]

My child is moody or irritable [71240-6]

My child worries when we go back to the hospital or clinic [71241-4]

My child gets nervous - frightened easily [71242-2]

My child worries about having a good life in the future [71243-0]

Social well being - FAACT-peds - parent_child [71275-2]

Other people pick on - tease my child [71272-9]

My child has fewer friends than others [71247-1]

Other children avoid playing with my child because s-he is different [71276-0]

My child seems lonely [71249-7]

My child prefers to play alone [71277-8]

My child thinks I worry too much about him/her [71224-0]

My child thinks I spoil him/her [71225-7]

Additional concerns - FAACT-parent [71251-3]

My child eats as much as s-he wants [71252-1]

My child eats enough to do whatever s-he needs to do [71253-9]

My child is worried about his-her weight [71254-7]

Most food tastes bad to my child [71255-4]

My child is worried about how thin s-he is [71256-2]

As soon as my child starts eating, s-he feels like stopping [71257-0]

My child is afraid to eat because it may make her-him sick [71258-8]

Family or friends try to get my child to eat more [71273-7]

My child has been throwing up [71260-4]

When my child eats, s-he seems to get full quickly [71261-2]

My child has pain in his-her stomach [71262-0]

My child feels like s-he is getting better [71263-8]

Pediatric - functional assessment of anorexia cachexia questionnaire - 10 items - version 2 [71146-5]

I eat as much as I want [71152-3]

I eat enough food for me to do whatever I need to do [71153-1]

Most food tastes bad to me [71154-9]

As soon as I start eating, I feel like stopping [71155-6]

I am afraid to eat because it may make me sick [71156-4]

My family or friends try to get me to eat more [71157-2]

I have been throwing up [71158-0]

When I eat, I seem to get full quickly [70684-6]

I have pain in my stomach [71159-8]

I feel like I am getting better [71160-6]

Pediatric - patients with brain cancer - adolescent questionnaire - version 2 [71147-3]

Physical well being - FACIT-peds [71216-6]

I lose balance or fall down easily [71163-0]

I have trouble getting myself dressed [71164-8]

I have trouble running like other children [71165-5]

I get tired easily [70528-5]

My arms or legs feel weak [71166-3]

I get ill easily [71167-1]

I have trouble writing with a pen or pencil [71168-9]

I have pain [70408-0]

Emotional well being and illness experience - FACT-Br -peds-adoles [71315-6]

I feel happy [71285-1]

When I try to do something, I usually believe I will do it well [71286-9]

The illness experience makes me a stronger person [71287-7]

The illness experience has taught me to appreciate life [71288-5]

I often feel that other people are better than me [71289-3]

I worry about being sick again [71290-1]

I often switch from good moods to bad moods [71291-9]

I worry when I go back to the hospital or clinic [71292-7]

I get nervous - frightened easily [71293-5]

I worry about having a good life in the future [71294-3]

I worry about being able to date because of my illness history [71295-0]

I worry about being able to go to college because of my illness history [71296-8]

I worry about getting a job to support myself because of my illness history [71297-6]

Social - family well being - FACT-Br-peds [71317-2]

Other people pick on - tease me [71298-4]

I think I have fewer friends than others [71299-2]

Other people avoid hanging out with me because of my illness history [71300-8]

I feel lonely [71301-6]

I would rather do something by myself than with other people [71302-4]

Additional concerns - FACT-Br-peds [71228-1]

I am bothered by being shorter than other people [71303-2]

I am bothered by being unable to see well [71304-0]

I am bothered by being unable to hear well [71305-7]

I am bothered by headaches [71306-5]

When I speak, people have trouble understanding [71307-3]

I need to work harder than other people to get my school work done [71308-1]

My grades are worse than they were before I was sick [71309-9]

I forget things easily [71310-7]

It is hard for me to concentrate in school [71311-5]

I have to read things several times so I can understand them [71312-3]

When I play games or sports, I react more slowly than most people my age [71313-1]

It is hard for me to find the right words to say what I mean [71314-9]

Pediatric - patients with brain cancer - child questionnaire - version 2 [71148-1]

Physical well being - FACIT-peds [71216-6]

I lose balance or fall down easily [71163-0]

I have trouble getting myself dressed [71164-8]

I have trouble running like other children [71165-5]

I get tired easily [70528-5]

My arms or legs feel weak [71166-3]

I get ill easily [71167-1]

I have trouble writing with a pen or pencil [71168-9]

I have pain [70408-0]

Emotional well being and illness experience - FACT-Br -peds-child [71316-4]

I feel happy [71285-1]

When I try to do something, I usually believe I will do it well [71286-9]

The illness experience makes me a stronger person [71287-7]

The illness experience has taught me to appreciate life [71288-5]

I often feel that other children are better than me in the past 4W [71289-3]

I worry about being sick again [71290-1]

I often switch from good moods to bad moods [71291-9]

I worry when I go back to the hospital or clinic [71292-7]

I get nervous - frightened easily [71293-5]

I worry about having a good life in the future [71294-3]

Social - family well being - FACT-Br-peds [71317-2]

Other people pick on - tease me [71298-4]

I think I have fewer friends than others [71299-2]

Other people avoid hanging out with me because of my illness history [71300-8]

I feel lonely [71301-6]

I would rather do something by myself than with other people [71302-4]

Additional concerns - FACT-Br-peds [71228-1]

I am bothered by being shorter than other people [71303-2]

I am bothered by being unable to see well [71304-0]

I am bothered by being unable to hear well [71305-7]

I am bothered by headaches [71306-5]

When I speak, people have trouble understanding [71307-3]

I need to work harder than other people to get my school work done [71308-1]

My grades are worse than they were before I was sick [71309-9]

I forget things easily [71310-7]

It is hard for me to concentrate in school [71311-5]

I have to read things several times so I can understand them [71312-3]

When I play games or sports, I react more slowly than most people my age [71313-1]

It is hard for me to find the right words to say what I mean [71314-9]

Pediatric - patients with brain cancer - parent_adolescent questionnaire - version 1 [71149-9]

Physical well being - FACT-Br -peds-parent [71318-0]

My child loses balance or falls down easily [71195-2]

My child has trouble getting dressed on his-her own [71196-0]

My child has trouble running like other people [71197-8]

My child gets tired easily [71198-6]

My child's arms or legs seem weak [71199-4]

My child gets ill [71200-0]

My child has trouble writing with a pen or pencil [71201-8]

Emotional well being - FACT-Br -peds-parent_adoles [71319-8]

My child seems happy [71203-4]

When my child tries to do something, s/he usually believes s/he will do it well [71204-2]

The illness experience makes my child a stronger person [71232-3]

The illness experience has taught my child to appreciate life [71231-5]

My child often feels inferior to other people [71207-5]

My child worries about getting another cancer/tumor [71208-3]

My child is moody or irritable [71209-1]

My child worries when we go back to the hospital or clinic [71210-9]

My child gets nervous (frightened) easily [71211-7]

My child worries about having a good life in the future [71212-5]

Social and family well being - FACT-Br -peds-parent_adoles [71322-2]

Other people pick on (tease) my child [71219-0]

My child has fewer friends than others [71220-8]

Other people avoid hanging out with my child because s/he is different [71221-6]

My child seems lonely [71222-4]

My child prefers to do something alone [71223-2]

Additional concerns - FACT-Br-parent [71229-9]

My child is bothered by being shorter than his-her peers [71323-0]

My child is bothered by poor vision [71324-8]

My child is bothered by poor hearing [71325-5]

My child is bothered by headaches [71326-3]

My child's speech is hard for others to understand [71327-1]

My child needs to work harder than his-her peers to get school work done [71328-9]

My child's school performance is worse than it was before s-he was diagnosed [71329-7]

My child forgets things easily [71330-5]

It is hard for my child to concentrate in school [71331-3]

My child has to read things several times so s-he can understand them [71332-1]

When my child plays games or sports, s-he reacts more slowly than his-her peers [71333-9]

My child has difficulty using the right words [71334-7]

Pediatric - patients with brain cancer - parent_child questionnaire - version 1 [71150-7]

Physical well being - FACT-Br -peds-parent [71318-0]

My child loses balance or falls down easily [71195-2]

My child has trouble getting dressed on his-her own [71196-0]

My child has trouble running like other children in the past 4W [71197-8]

My child gets tired easily [71198-6]

My child's arms or legs seem weak [71199-4]

My child gets ill [71200-0]

My child has trouble writing with a pen or pencil [71201-8]

Emotional well being - FACT-Br -peds-parent_child [71320-6]

My child seems happy [71203-4]

When my child tries to do something, s/he usually believes s/he will do it well [71204-2]

The illness experience makes my child a stronger person [71232-3]

The illness experience has taught my child to appreciate life [71231-5]

My child often feels inferior to other children [71335-4]

My child worries about getting another cancer/tumor [71208-3]

My child is moody or irritable [71209-1]

My child worries when we go back to the hospital or clinic [71210-9]

My child gets nervous (frightened) easily [71211-7]

My child worries about having a good life in the future [71212-5]

Social and family well being - FACT-Br -peds-parent_child [71321-4]

Other people pick on (tease) my child [71219-0]

My child has fewer friends than other children in the past 4W [71220-8]

Other children avoid playing with my child because s-he is different [71276-0]

My child seems lonely [71222-4]

My child prefers to play alone [71277-8]

Pediatric - functional assessment of chronic illness therapy - fatigue questionnaire [71151-5]

I feel tired [70304-1]

I have energy (or strength) [71161-4]

I could do my usual things at home [71162-2]

I had trouble starting things because I was too tired [71379-2]

I had trouble finishing things because I was too tired [71380-0]

I needed to sleep during the day [71381-8]

I got upset by being too tired to do things I wanted to do [71382-6]

Being tired made it hard for me to play or go out with my friends as much as I'd like [71383-4]

I feel weak [71336-2]

I needed help doing my usual things at home [71385-9]

I was too tired to eat [71384-2]

Being tired made me sad [71337-0]

Being tired made me mad-angry [71338-8]

PLEASE WAIT