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Functional Assessment of Cancer Therapy for patients with endocrine symptoms questionnaire - version 4 (FACT-ES) [FACIT] [70800-8]

Date Done

Time Done

Where Done

Comment

Name

Value

Units

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-ES [70898-2]

I have hot flashes [70376-9]

I have cold sweats [70378-5]

I have night sweats [70379-3]

I have vaginal discharge [70380-1]

I have vaginal itching/irritation [70801-6]

I have vaginal bleeding or spotting [70381-9]

I have vaginal dryness [70802-4]

I have pain or discomfort with intercourse [70382-7]

I have lost interest in sex [70803-2]

I have gained weight [70377-7]

I feel light-headed (dizzy) [70560-8]

I have been vomiting [70479-1]

I have diarrhea [70349-6]

I get headaches [70302-5]

I feel bloated [70656-4]

I have breast sensitivity/tenderness [70804-0]

I have mood swings [70805-7]

I am irritable [70806-5]

I have pain in my joints [70670-5]

Su	Mo	Tu	We	Th	Fr	Sa
						1
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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