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  5. MDASI-HN 2017
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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 presentAs 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 InterfereInterfered 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 : 
Zipcode : 
Phone : 
Email Address : 
 
 
 
* Time point at which the questionnaire was filled:
 
 
* Section I: Initial Disease Characteristics: 

1. (a) Primary cancer site:
 
 
 
1. (b) Oropharyngeal cancer subsite of origin:
 
 
 
* 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