FACT-G (Version 4) Hope4Cancer Survey Tool - Follow Up Visit

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

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* 2. ENTER YOUR NAME

PHYSICAL WELL-BEING

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* 5. GP1  I have a lack of energy

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* 6. GP2 I have nausea

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

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* 8. GP4 I have pain

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* 9. GP5 I am bothered by the side effects of treatment

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* 10. GP6 I feel ill

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* 11. GP7 I am forced to spend time in bed

SOCIAL / FAMILY WELL-BEING

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* 12. GS1 I feel close to my friends

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* 13. GS2 I get emotional support from my family

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* 14. GS3 I get support from my friends

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* 15. GS4 My family has accepted my illness

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* 16. GS5 I am satisfied with family communication about my illness

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

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* 18. 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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* 19. GS7 I am satisfied with my sex life

EMOTIONAL WELL-BEING

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* 20. GE1 I feel sad

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

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

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* 23. GE4 I feel nervous

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* 24. GE5 I worry about dying

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* 25. GE6 I worry that my condition will get worse

FUNCTIONAL WELL-BEING

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

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

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* 28. GF3 I am able to enjoy life

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* 29. GF4 I have accepted my illness

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* 30. GF5 I am sleeping well

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

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

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* 33. What was the date you were admitted for your current follow up visit?

Date

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* 34. What is your date of discharge from your follow up visit?

Date

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* 35. 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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* 36. What is the stage of your cancer?

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* 37. If your cancer was not officially assigned a stage, what do you believe is the approximate staging of your cancer?

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* 38. My first treatment was at:

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* 39. My current follow up visit is at:

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* 40. I am continuing with the following treatments at home (select all that apply):

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* 41. I am 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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* 42. This is my current height in feet and inches (without shoes):

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

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