FACT-G (Version 4) Hope4Cancer Survey Tool

Below is a list of statements that other people with your illness have said are important. Please circle or mark one number per line to indicate your response as it applies to the past 7 days.

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* ENTER YOUR PATIENT ID (If you don't know your ID, skip to the next question)

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* ENTER YOUR NAME

PHYSICAL WELL-BEING

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* GP1  I have a lack of energy

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* GP2 I have nausea

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* GP3 Because of my physical condition, I have trouble meeting the needs of my family

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* GP4 I have pain

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* GP5 I am bothered by the side effects of treatment

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* GP6 I feel ill

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* GP7 I am forced to spend time in bed

SOCIAL / FAMILY WELL-BEING

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* GS1 I feel close to my friends

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* GS2 I get emotional support from my family

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* GS3 I get support from my friends

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* GS4 My family has accepted my illness

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* GS5 I am satisfied with family communication about my illness

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* GS6 I feel close to my partner (or the person who is my main support)

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* Regardless of your current level of sexual activity, please answer the question below. If you prefer not to answer it, mark this box and go to the next section.

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* GS7 I am satisfied with my sex life

EMOTIONAL WELL-BEING

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* GE1 I feel sad

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* GE2 I am satisfied with how I am coping with my illness

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* GE3 I am losing hope in the fight against my illness

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* GE4 I feel nervous

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* GE5 I worry about dying

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* GE6 I worry that my condition will get worse

FUNCTIONAL WELL-BEING

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* GF1 I am able to work (Include work at home)

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* GF2 My work (including work at home) is fulfiling

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* GF3 I am able to enjoy life

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* GF4 I have accepted my illness

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* GF5 I am sleeping well

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* GF6 I am enjoying the things I usually do for fun

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* GF7 I am content with the quality of my life right now

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* What was your date of admission at Hope4Cancer?

Date

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* What is your date of discharge from Hope4Cancer?

Date

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* What is your primary cancer? Even if you had cancer in the past, please report the primary form of cancer. If you have more than one primaries, select all that apply.

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* What is the stage of your cancer?

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* I was being treated at:

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* [BAJA CLINIC PATIENTS ONLY] I am an:

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* My treatment plan includes the following treatments (select all that apply):

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* I am continuing with the following treatments in my home program (select all that apply):

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* I am also considering purchasing equipment to continue the following therapies at home (select all that apply) - please consult your assigned doctor before starting any of these treatments at home:

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* This is my current height in feet and inches (without shoes):

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* This is my current weight (in pounds), no shoes:

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