Patient Follow-up Form - Version 1.1
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1 Physician: [Last Name GO PROJECT Patient Follow-up Form - Version 1.1 Thank you for participating in the Glioma Outcomes Project. To continue participating in this important project, complete or correct the following information. This -month Patient Follow-up Form has been mailed directly to you by the Data Coordinating Center. A similar form will be mailed to you again in approximately 3 months. Please print or type. Thank You! Physician Information Neurosurgeon First Name Last Name Hospital / Clinic Patient Information Patient Name Social Security Number (or Social Insurance Number in Canada) Address City State Zip / Postal Code Telephone Number ( ) - Alternate Phone Number ( ) - Patient Contact Person Name Relationship Address City State Zip / Postal Code Telephone Number ( ) - Alternate Phone Number ( ) - The date of your most recent brain surgery was / / If this is incorrect, please provide the date of your most recent brain surgery / / Demographic Information Date of Birth / / Sex! Male! Female Height feet inches Are you! Right Handed! Left handed! Ambidextrous (Both) Ethnic Background (Please check all that apply)! White/Caucasian! Black/African American! Hispanic! Oriental/Asian, Pacific Islander! American Indian, Eskimo/Aleutian! Other (Specify )! Prefer Not to Answer The Glioma Outcomes Project Patient Follow-up Form -- Version 1.1 Page 1 of 7
2 1. Date of Completion (Today's Date) / / 2. Form filled out by! Patient with no help! Patient with help from family and/or friend! Patient with help from health care provider! Family member or friend! Health care provider! Other (Specify ) 3. What is your weight? (Please use a weight taken within the last week) Pounds 4. Compared to 3 months ago, has your weight gone! Down! Up! Stayed the Same! Don t know 5. Have you received chemotherapy for your brain tumor within the past 3 months? 6. Have you received radiation therapy for your brain tumor within the past 3 months? 7. Have you used any alternative treatments for your brain tumor within the past 3 months? High dose vitamins...!! Herbs...!! Macrobiotic diet...!! Shark cartilage...!! Antineoplastins...!! 7. (continued) Have you used any alternative treatments for your brain tumor within the past 3 months? Hydrazine...!! Acupuncture...!! Faith healer...!! Meditation...!! Other...!! Specify 8. Have you enrolled in a formal clinical brain tumor trial (other than the GO Project) within the past 3 months? (Specify )! Don't know Glioma Outcomes Questionnaire 9. Please indicate how you felt during the past week (choose one answer on each line) Not at Some Quite a Very all what bit much a. I can remember new things...!!!! b. I have trouble with my vision...!!!! c. I am able to find the right word(s) to say what I mean...!!!! d. I have trouble expressing my thoughts...!!!! e. I am able to put my thoughts into action...!!!! f. My personality has changed...!!!! g. I have weakness in some parts of my body...!!!! h. I have trouble with my coordination...!!!! i. I have had seizures...!!!! j. I have had headaches...!!!! k. I get tired easily...!!!! l. I am slower to do things...!!!! m. I feel sick...!!!! n. I spend time in bed...!!!! o. I need help caring for myself (bathing, dressing, eating, etc)!!!! The Glioma Outcomes Project Patient Follow-up Form -- Version 1.1 Page 2 of 7
3 9. (continued) Please indicate how you felt during the past week (choose one answer on each line) Not at Some Quite a Very all what bit much p. I get support from my family...!!!! q. I feel sad...!!!! r. I am able to work (include work in home)...!!!! s. I am able to drive...!!!! t. I am able to enjoy my usual leisure pursuits...!!!! u. I am content with the quality of my life...!!!! SF-36 Health Survey* This survey asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. Answer every question by marking the answer as indicated. If you are unsure about how to answer a question, please give the best answer you can. 10. In general, would you say your health is (choose one)! Excellent! Very good! Good! Fair! Poor 11. Compared to 3 months ago, how would you rate your health in general now? (choose one)! Much better now than 3 months ago! Somewhat better now than 3 months ago! About the same! Somewhat worse now than 3 months ago! Much worse now than 3 months ago 12. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (choose one answer on each line) Yes, Yes, No, not limited limited limited a lot a little at all a. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports...!!! b. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf...!!! c. Lifting or carrying groceries...!!! d. Climbing several flights of stairs...!!! e. Climbing one flight of stairs...!!! f. Bending, kneeling, or stooping...!!! g. Walking more than a mile...!!! h. Walking several blocks...!!! i. Walking one block...!!! j. Bathing or dressing yourself...!!! 13. During the past week, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? (choose one answer on each line) a. Cut down on the amount of time you spent on work or other activities...!! b. Accomplished less than you would like...!! c. Were limited in the kind of work or other activities...!! d. Had difficulty performing the work or other activities (for example, it took extra effort)...!! The Glioma Outcomes Project Patient Follow-up Form -- Version 1.1 Page 3 of 7
4 14. During the past week, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? (choose one answer on each line) a. Cut down the amount of time you spent on work or other activities...!! b. Accomplished less than you would like..!! c. Didn't do work or other activities as carefully as usual...!! 15. During the past week, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? (choose one) t at all! Slightly! Moderately! Quite a bit! Extremely 16. How much bodily pain have you had during the past week? (choose one) ne! Very mild! Mild! Moderate! Severe! Very severe 17. During the past week, how much did pain interfere with your normal work (including both work outside the home and housework)? (choose one) t at all! A little bit! Moderately! Quite a bit! Extremely 18. These questions are about how you feel and how things have been with you during the past week. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past week (choose one answer on each line) All Most A good Some A None of of bit of of little of the the the the of the the time time time time time time a. Did you feel full of pep?..!!!!!! b. Have you been a very nervous person?...!!!!!! c. Have you felt so down in the dumps that nothing could cheer you up?...!!!!!! d. Have you felt calm and peaceful?...!!!!!! e. Did you have a lot of energy?...!!!!!! f. Have you felt downhearted and blue?..!!!!!! g. Did you feel worn out?...!!!!!! h. Have you been a happy person?...!!!!!! i. Did you feel tired?...!!!!!! 19. During the past week, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? (choose one)! All of the time! Most of the time! Some of the time! A little of the time ne of the time 20. How TRUE or FALSE is each of the following statements for you? (choose one answer on each line) Definitely Mostly Don't Mostly Definitely True True Know False False a. I seem to get sick a little easier than other people...!!!!! b. I am as healthy as anybody I know....!!!!! c. I expect my health to get worse...!!!!! d. My health is excellent...!!!!! The Glioma Outcomes Project Patient Follow-up Form -- Version 1.1 Page 4 of 7
5 21. In the past 3 months, have you had 2 weeks or more during which you felt sad, blue, or depressed; or when you lost all interest or pleasure in things that you usually cared about or enjoyed? 22. Have you felt depressed or sad much of the time in the past 3 months? 26. What health insurance provides your coverage? None...!! Medicare...!! Medex or other Medicare supplement...!! Medicaid...!! Health Maintenance Organization (HMO)...!! BC/BS or other commercial insurance...!! CHAMPUS (government)...!! Canadian Provincial Insurance...!! Other (Specify )...!! Demographic and Social Information 23. Marital Status! Married! Never Married! Divorced! Separated! Widowed! Prefer not to Answer 24. Do you live with someone who can help take care of you? 25. Are you receiving home care services? (Specify ) 27. In providing payment for the care of my brain tumor, my insurance company has been! Very helpful! Somewhat helpful! Unhelpful t applicable 28. Are you currently working?! Full-time! Part-time 29. Have you changed jobs within the past 3 months?! Same job! Different job t working 30. Are you receiving disability benefits? The Glioma Outcomes Project Patient Follow-up Form -- Version 1.1 Page 5 of 7
6 31. How knowledgeable do you feel about your brain tumor?! Very knowledgeable! Somewhat knowledgeable! Need more information 32. Which organizations have given you information or help with your brain tumor? American Cancer Society...!! American Brain Tumor Association...!! National Brain Tumor Foundation...!! Others...!! Specify 33. What additional information would you like to have about brain tumors? 34. What would you tell other patients and their families about brain tumors or their treatment? 35. Are you part of a brain tumor support group? 36. If you could go back in time and make the same decision again, would you choose to have your most recent brain tumor surgery?, definitely, probably, probably not, definitely not t applicable 37. If you could go back in time and make the same decision again, would you choose to have chemotherapy for your brain tumor?, definitely, probably, probably not, definitely not t applicable 38. If you could go back in time and make the same decision again, would you choose to have radiation therapy for your brain tumor?, definitely, probably, probably not, definitely not t applicable 39. Do you feel that you have had access to all the health care you need for your brain tumor? The Glioma Outcomes Project Patient Follow-up Form -- Version 1.1 Page 6 of 7
7 40. In general, have you been satisfied with the medical care you have received for your brain tumor?! Very satisfied! Somewhat satisfied t Satisfied! Very Unsatisfied 41. Do you feel that the questions in this form are relevant to your health? 42. Do you plan to continue to participate in the GO Project? Thank You for Completing This Questionnaire Please return the completed form in the envelope provided. If you lose the envelope and want another, call Our address is GO Project Center for Outcomes Research Department of Surgery UMass Medical School 365 Plantation Street, Suite 185 Worcester, MA Questions comprise the SF-36 Health Survey 1992 Medical Outcomes Trust. All Rights Reserved. Reproduced with permission of the Medical Outcomes Trust. (Reason: ) 43. Comments The Glioma Outcomes Project Patient Follow-up Form -- Version 1.1 Page 7 of 7
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