This free survey is powered by
Create a Survey
Surveys
2017
June
M
MDASI-HN 2017
MDASI-HN 2017
Welcome!
0%
Exit Survey
Hello champions:
Congratulations! You've completed cancer treatment and have a new outlook on life. At MD Anderson, we know that being a cancer survivor brings its own set of challenges that affect every aspect of your life. It's our goal to make life after cancer the best it can be, and we have the resources to help you get there.
You are cordially invited to participate in our
MDASI-HN
questionnaire [multi-symptom patient-reported outcome (PRO) measure]. In this questionnaire, you will be asked to complete a survey that asks questions about symptom severity, if any, and its interference with daily life. It will take approximately 15 minutes to complete the questionnaire.
Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.
Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact [Name of Survey Researcher] at [Phone Number] or by email at [email address].
Thank you very much for your time and support. Surviving cancer is a lifelong commitment that we , at MD Anderson, are fully devoted to.
Please start with the
MDASI-HN
questionnaire now by clicking on the 'Next' button below.
Part I. How severe are your symptoms?
People with cancer frequently have symptoms that are caused by their disease or by their treatment. We ask you to rate how severe the following symptoms have been in the last 24 hours. Please fill in the circle below from 0 (symptom has not been present) to 10 (the symptom was bad as bad as you can imagine it could be) for each item.
Not present
As bad as you can imagine
0
1
2
3
4
5
6
7
8
9
10
*
1. Your
pain
at its WORST?
*
2. Your
fatigue (tiredness)
at its WORST?
*
3. Your
nausea
at its WORST?
*
4. Your
disturbed sleep
at its WORST?
*
5. Your feelings of being
distressed (upset)
at its WORST?
*
6. Your
shortness of breath
at its WORST?
*
7. Your problem with
remembering things
at its WORST?
*
8. Your problem with
lack of appetite
at its WORST?
*
9. Your feeling
drowsy (sleepy)
at its WORST?
*
10. Your having a
dry mouth
at its WORST?
*
11. Your feeling
sad
at its WORST?
*
12. Your
vomiting
at its WORST?
*
13. Your
numbness or tingling
at its WORST?
Part II. How have your symptoms interfered with your life?
Symptoms frequently interfere with how we feel and function. How much have your symptoms interfered with the following items in the last 24 hours:
Did Not Interfere
Interfered completely
0
1
2
3
4
5
6
7
8
9
10
*
14.
General activity?
*
15.
Mood?
*
16.
Work (including work around the house)?
*
17.
Relations with other people?
*
18.
Walking?
*
19.
Enjoyment of life?
*
Subject Dummy ID:
Contact Information
First Name
:
Last Name
:
Address Line 1
:
Address Line 2
:
City
:
State
:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
Zipcode
:
Phone
:
Email Address
:
*
Time point at which the questionnaire was filled:
-- Select --
Baseline
3-6 month follow-up
9-12 month follow-up
16-19 month follow-up
21-24 month follow-up
*
Section I: Initial Disease Characteristics:
1. (a) Primary cancer site:
-- Select --
Cervical esophagus
Glottic larynx
Hypopharynx
Nasopharynx
Minor salivary gland
Oropharynx
Parotid gland
Subglottic larynx
Submandibular gland
Subglottic larynx
Supraglottic larynx
Thyroid
1. (b) Oropharyngeal cancer subsite of origin:
-- Select --
Base of tongue
Glossopharyngeal sulcus
Pharyngeal wall
Soft palate
Tonsil
Vallecula
*
2. Histology type:
Squamous cell carcinoma
Undifferentiated carcinoma
Nasopharyngeal carcinoma WHO type 1
Nasopharyngeal carcinoma WHO type 2
Nasopharyngeal carcinoma WHO type 3
Adenoid cystic carcinoma
Mucoepidermoid carcinoma
Adenocarcinoma
Thyroid carcinoma
Carcinoma, NOS
MDASI-HN
Loading...
close
Loading...
Close
qprun1.questionpro.net