Form 340. Life and Longevity after Cancer BASELINE QUESTIONNAIRE. Instructions:
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1 CENER PERF Form MARKING INSRUCIONS Use a pencil. Darken he circle compleely nex o he answer you choose. Erase cleanly any marks you wish o change. Do no make any sray marks on his form. R:DOCEXFORMSCURRF.DOC / BASELINE QUESIONNAIRE Insrucions: o help us learn more abou cancer reamens and heir effecs on he lives of women, we would like o ask more informaion abou he cancer you have had. When compleing he quesions abou cancer, please refer only o he cancer noed in he cover leer. Please answer each quesion as bes you can for his specific ype of cancer. his bookle has wo secions. he firs secion is abou he cancer, cancer reamens, and healh issues afer cancer reamen. he quesions abou reamen are abou he reamens ha you received righ afer he cancer diagnosis. he secion also includes quesions abou healh insurance. he second secion is abou your experience since he diagnosis of cancer. AFFIX LABEL BEWEEN LINES BAR CODE HERE he LILAC Sudy Life and Longeviy afer Cancer OFFICE USE ONLY Language:» PLEASE MAKE NO MARKS IN HIS AREA E S Dae Received: Reviewed By: Pg. of 8 CORREC MARK» INCORREC MARKS Monh Day Year RCR SERIAL # Ver.
2 Ver. Form Life and Longeviy Afer Cancer (LILAC) Please complee he following quesions regarding reamens you may have had for cancer. If you have had more han one ype of cancer, please refer only o he cancer noed in he cover leer.. Afer you were firs diagnosed wih cancer, did you have chemoherapy? his means you ook a drug by pill or hrough an IV o kill cancer cells. Some drugs migh have made you sick o your somach, lose your hair, or ich, for example. Go o quesion below. Don know Name of docor and faciliy where you received chemoherapy.. Docor s name:. Name of faciliy:. Ciy and Sae of faciliy:. Dae chemoherapy sared: - monh year. Dae chemoherapy ended: - monh year. Did you have radiaion o rea your cancer? here are wo ypes of radiaion reamen o consider: Beam radiaion (exernal radiaion) is given by a machine in a hospial or clinic and direced o a specific par of your body; or an implan (inernal radiaion) is placed in your body, usually under aneshesia, and delivers radiaion coninuously. Go o he nex page. Don know Name of docor and faciliy where you received radiaion herapy.. Docor s name:. Name of faciliy:. Ciy and Sae of faciliy:. Dae radiaion sared: - monh year. Dae radiaion ended: - monh year Go o he nex page. R:DOCEXFORMSCURRF.DOC / Pg. of 8 CENER PERF
3 CENER PERF Form Life and Longeviy Afer Cancer (LILAC). Some cancers, such as breas cancer and endomerial cancer, are reaed wih hormone-relaed or ani-esrogen pills. Some common pills include amoxifen, Arimidex, Femara, and Megace. Did you use hormonal reamens for your cancer? Don know Name of docor who prescribed he firs hormonal herapy afer he diagnosis of he cancer.. Docor s name:. Name of faciliy:. Ciy and Sae of faciliy:. Did a differen docor prescribe he mos recen hormonal herapy? Name of docor who prescribed he mos recen hormonal herapy.. Docor s name:.6 Name of faciliy:. 7 Ciy and Sae of faciliy: Go o he nex page. Go o he nex page..8 Dae firs hormonal herapy sared: - monh year. Dae firs hormonal herapy ended: - monh year PLEASE MAKE NO MARKS IN HIS AREA R:DOCEXFORMSCURRF.DOC / Pg. of 8 Go o he nex page. SERIAL # Ver.
4 Ver. Form Life and Longeviy Afer Cancer (LILAC). Did you have any oher ype of reamen for your cancer such as Hercepin (a pill), a umor vaccine (a sho), or a sem cell or bone marrow ransplan (clinic procedure)? Go o he nex page. Don know reamen Docor and Faciliy. Hercepin Docor s name: Name of faciliy: Ciy and Sae of faciliy: Dae reamen sared: -. umor Docor s name: Vaccine Name of faciliy: monh year Ciy and Sae of faciliy: Dae reamen sared: -. ransplan Docor s name: Name of faciliy: monh year Ciy and Sae of faciliy: Dae reamen sared: -. Oher Docor s name: Name of faciliy: Specify: Ciy and Sae of faciliy: monh year Dae reamen sared: - monh year Go o he nex page. R:DOCEXFORMSCURRF.DOC / Pg. of 8
5 Form Life and Longeviy Afer Cancer (LILAC) R:DOCEXFORMSCURRF.DOC / Pg. of 8. We are ineresed in learning abou any healh issues ha you experienced afer he compleion of your iniial cancer reamens. Please indicae he sympoms ha were NEW o you afer your cancer reamen, and no due o some oher known medical condiion. Did his occur? If yes, how soon afer reamen did sympoms occur -- in a maer of days, monhs, or years? Do you sill have he sympom? Have you been reaed for he sympom? Monhs Years Days Ver.. Low blood couns (anemia, neuropenia). Blood clos (venous hromboembolisms). High blood pressure. Kidney problems. Liver problems. Memory problems. Aching joins. Ho flashes. Radiaion burns. Shorness of breah. Mouh sores or dry mouh. Insomnia or sleep problems.7 Bleeding oo easily.8 Weigh gain > lbs.. Oher: Specify:.6 Nerve problems ingling sensaions.8 Skin rash or oher skin disorders.6 Hear disease, like congesive hear failure.7 Hearing changes Go o he nex page.
6 Ver. Recurrence Don know 6. Docor s name: 6. Ciy and Sae: 6. Dae: - monh year Insurance ype of Insurance 7. Medicare (federal healh insurance for people age 6 or older or who are disabled). 7. Medicare supplemen (Addiional insurance o Medicare ha you buy yourself, such as Medex, Medigap, or AARP). 7. Medicaid (sae program for persons wih incomes below a cerain level). 7. Privae or commercial insurance (such as Blue Cross, Aena, Prudenial, or Hancock). 7. HMO (Healh Mainenance Organizaion, such as Kaiser Permanene, Group Healh Cooperaive) or IPA (Individual Pracice Associaion). 7.6 Veerans, CHAMPUS, or RICARE (insurance for people in he miliary and heir families). 7.7 Oher Sae medical assisance or free care programs. Specify: R:DOCEXFORMSCURRF.DOC / Pg. 6 of 8 Form Life and Longeviy Afer Cancer (LILAC) 6. Has your docor ever old you ha his cancer came back (a recurrence), ha i had spread, or ha you now have anoher cancer of his same ype? Go o quesion 7 below. Name of he docor who old you ha he cancer came back. 7. Please ell us he ype of healh insurance ha you had when you were firs diagnosed wih cancer and he ype ha you currenly have. For each ype of insurance coverage, please mark one circle under Insurance coverage a diagnosis and one circle under Curren insurance coverage. Insurance coverage a diagnosis Don Know PLEASE MAKE NO MARKS IN HIS AREA Curren insurance coverage Don Know Go o he nex page. SERIAL #
7 R:DOCEXFORMSCURRF.DOC / Form Life and Longeviy Afer Cancer (LILAC) hese nex quesions refer o he presen ime. 8. Do you ofen feel sad or depressed? (Please mark he bes answer).. Please rae your pain by marking one circle ha bes describes your pain a is wors in he las hours. pain ne ne ne Moderae Moderae Moderae ne of How ofen is someone available he ime. o ake you o he docor if you need o go? Pg. 7 of 8 Wors Wors Wors Ver. Pain as bad as you can imagine. Please mark one circle below o bes reflec your feelings during he pas week, including oday.. Your overall level of anxiey?. Your overall level of faigue?. Your overall level of disress?. People someimes look o ohers for companionship, assisance, or oher ypes of suppor. his quesion covers he ypes of suppor ha would be available o you if you needed i. Please mark one circle based on he suppor available o you during he pas weeks..... o have a good ime wih? o hug you? o prepare your meals if you are unable o for yourself? o undersand your problems? A lile of he ime Some of he ime Mos of he ime All of he ime Go o he nex page.
8 Ver.. How ofen do you feel you lack companionship?. How ofen do you feel lef ou?. How ofen do you feel isolaed from ohers?. Wha is your curren weigh?. Wha is your curren marial saus? Married/living as married Widowed R:DOCEXFORMSCURRF.DOC / Pg. 8 of 8 Form Life and Longeviy Afer Cancer (LILAC). In he nex secion is a se of saemens abou how you migh feel. Please indicae which of he following four possible answers bes capures how ofen you feel he way ha is described in each saemen. hank you. Please ake a momen o review any quesions you may have missed. lbs. Commens Ofen PLEASE MAKE NO MARKS IN HIS AREA Divorced/separaed Never married Some of he ime Hardly ever (or never) SERIAL # answer OFFICE USE ONLY OpScan insigh EM--:6
Form 370 LILAC Annual Survey. Darken the circle completely next to the answer you choose. \ \»
CENER PERF Chemoherapy Radiaion herapy Form 7 LILAC Annual Survey he LILAC Sudy Life and Longeviy afer Cancer hank you for compleing he survey we sen las year. his year we are asking quesions abou how
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