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Functional Assessment of Cancer Therapy for patients with cognitive function issues questionnaire - version 3 (FACT-Cog) [FACIT] [70759-6]

Date Done

Time Done

Where Done

Comment

Name

Value

Units

Perceived cognitive impairments [70849-5]

I have had trouble forming thoughts [70760-4]

My thinking has been slow [70761-2]

I have had trouble concentrating [70762-0]

I have had trouble finding my way to a familiar place [70763-8]

I have had trouble remembering where I put things, like my keys or my wallet [70764-6]

I have had trouble remembering new information, like phone numbers or simple instructions [70765-3]

I have had trouble recalling the name of an object while talking to someone [70766-1]

I have had trouble finding the right words to express myself [70767-9]

I have used the wrong word when I referred to an object [70768-7]

I have had trouble saying what I mean in conversations with others [70769-5]

I have walked into a room and forgotten what I meant to get or do there [70770-3]

I have had to work really hard to pay attention or I would make a mistake [70771-1]

I have forgotten names of people soon after being introduced [70772-9]

My reactions in everyday situations have been slow [70773-7]

I have had to work harder than usual to keep track of what I was doing [70776-0]

My thinking has been slower than usual [70777-8]

I have had to work harder than usual to express myself clearly [70778-6]

I have had to use written lists more often than usual so I would not forget things [70779-4]

I have trouble shifting back and forth between different activities that require thinking [70781-0]

Comments from others [70774-5]

Other people have told me I seemed to have trouble remembering information [70775-2]

Other people have told me I seemed to have trouble speaking clearly [70782-8]

Other people have told me I seemed to have trouble thinking clearly [70783-6]

Other people have told me I seemed confused [70784-4]

Perceived cognitive abilities [70785-1]

I have been able to concentrate [70786-9]

I have been able to bring to mind words that I wanted to use while talking to someone [70787-7]

I have been able to remember things, like where I left my keys or wallet [70788-5]

I have been able to remember to do things, like take medicine or buy something I needed [70789-3]

I am able to pay attention and keep track of what I am doing without extra effort [70790-1]

My mind is as sharp as it has always been [70791-9]

My memory is as good as it has always been [70792-7]

I am able to shift back and forth between two activities that require thinking [70793-5]

I am able to keep track of what I am doing, even if I am interrupted [70794-3]

Impact on quality of life [70795-0]

I have been upset about these problems [70796-8]

These problems have interfered with my ability to work [70797-6]

These problems have interfered with my ability to do things I enjoy [70798-4]

These problems have interfered with the quality of my life [70799-2]

Su	Mo	Tu	We	Th	Fr	Sa
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2	3	4	5	6	7	8
9	10	11	12	13	14	15
16	17	18	19	20	21	22
23	24	25	26	27	28	29
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