Time Point: 0 Initial



LEO (Lymphoma Epidemiology & Outcomes)Baseline Enrollment QuestionnaireTo be completed by Participant at time of Enrollment Mayo ClinicReturn to: Lymphoma/ CLL Study CoordinatorsCharlton 6Internal Ext: 870931-800-610-7093Instructions: Please answer the following questions to the best of your ability. This questionnaire is for research purposes only, and will not become part of your medical record.Date Form Completed____/____/________ (mm/dd/yyyy)Email AddressDate of Birth____/____/________ (mm/dd/yyyy)DEMOGRAPHICSGender FORMCHECKBOX Male FORMCHECKBOX FemaleAre you of Hispanic or Latino origin? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX I don’t knowWhich best describes your racial background? FORMCHECKBOX American Indian/Alaska Native FORMCHECKBOX Asian FORMCHECKBOX Black or African American FORMCHECKBOX White FORMCHECKBOX Native Hawaiian or other Pacific Islander FORMCHECKBOX None of the above FORMCHECKBOX I don’t knowWhat is your current weight?*__ __ __ poundsDEMOGRAPHICSWhat is your current height?*__ feet __ inchesWhat was your weight one month ago?*__ __ __ poundsWhat was your weight 6 months ago?*__ __ __ poundsDuring the past 2 weeks, did your weight:* FORMCHECKBOX decrease FORMCHECKBOX no change FORMCHECKBOX IncreaseAt the time of your lymphoma/CLL diagnosis, have you ever had any of the following diseases or conditions diagnosed by a health care professional?Heart Disease FORMCHECKBOX No (skip to next question) FORMCHECKBOX Yes (select all that apply) FORMCHECKBOX Coronary Heart Disease or Heart Attack (include stents) FORMCHECKBOX Congestive Heart Failure FORMCHECKBOX Pericardial Disease or Cardiomyopathy FORMCHECKBOX Heart Valve Disease FORMCHECKBOX Heart Rhythm Problems (Arrhythmias or Atrial Fibrillation) FORMCHECKBOX Other Heart DiseasePaRCStroke FORMCHECKBOX No FORMCHECKBOX YesSugar Diabetes FORMCHECKBOX No (skip to next question) FORMCHECKBOX Yes (select type below) FORMCHECKBOX Type 1 FORMCHECKBOX Type 2 FORMCHECKBOX Type UnknownRespiratory (breathing) disease FORMCHECKBOX No (skip to next question) FORMCHECKBOX Yes (select all that apply) FORMCHECKBOX Asthma FORMCHECKBOX Emphysema FORMCHECKBOX Chronic bronchitis FORMCHECKBOX Chronic obstructive pulmonary diseaseHepatitis FORMCHECKBOX No (skip to next question) FORMCHECKBOX Yes (select all that apply) FORMCHECKBOX Hepatitis A FORMCHECKBOX Hepatitis B FORMCHECKBOX Hepatitis C FORMCHECKBOX Don’t knowOther Liver problems FORMCHECKBOX No (skip to next question) FORMCHECKBOX Yes (select all that apply) FORMCHECKBOX Cirrhosis FORMCHECKBOX Non-alcoholic liver diseaseDigestive problems FORMCHECKBOX No (skip to next question) FORMCHECKBOX Yes (select all that apply) FORMCHECKBOX Ulcer FORMCHECKBOX Colitis Shingles FORMCHECKBOX No FORMCHECKBOX Yes Sinusitis FORMCHECKBOX No FORMCHECKBOX YesProgressive Multifocal Leukoencephalopathy (”PML”) FORMCHECKBOX No FORMCHECKBOX Yes Osteoporosis (Brittle Bones) FORMCHECKBOX No FORMCHECKBOX YesHip Fracture (broken hip) FORMCHECKBOX No FORMCHECKBOX YesOther Broken Bones FORMCHECKBOX No FORMCHECKBOX YesPremature Menopause FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX Not applicableInfertility FORMCHECKBOX No FORMCHECKBOX YesTaken medication or seen a health care provider for depression? FORMCHECKBOX No FORMCHECKBOX YesTaken medication or seen a health care provider for anxiety? FORMCHECKBOX No FORMCHECKBOX YesTaken medication or seen a health care provider for memory problems? FORMCHECKBOX No FORMCHECKBOX YesBlood Clot FORMCHECKBOX No (skip to next question) FORMCHECKBOX Yes (Please select all that apply) FORMCHECKBOX Deep Vein Thrombosis (DVT) Clot in legs or abdomen FORMCHECKBOX Pulmonary Embolism (PE) Clot in lungsAre you currently on Blood Thinning Medication? (NOT aspirin) FORMCHECKBOX No (skip to next question) FORMCHECKBOX Yes (Please provide type below) FORMCHECKBOX Coumadin (Warfarin) FORMCHECKBOX Heparin FORMCHECKBOX enoxaparin (Lovenox) FORMCHECKBOX dabigatran (Pradaxa) FORMCHECKBOX apixaban (Eliquis) FORMCHECKBOX rivaroxaban (Xarelto) FORMCHECKBOX Other FORMCHECKBOX Don’t knowHave you had an organ transplant? FORMCHECKBOX No FORMCHECKBOX Yes Specify ____________________________Autoimmune or other immune disorder? FORMCHECKBOX No (skip to next section) FORMCHECKBOX Yes (Please provide type below) FORMCHECKBOX Rheumatoid Arthritis (RA) FORMCHECKBOX Systemic Lupus Erythematosus (SLE) FORMCHECKBOX Wegner’s Granulomatosis (WG) FORMCHECKBOX Temporal Arteritis FORMCHECKBOX Systemic Vasculitis FORMCHECKBOX Sjogren’s Syndrome FORMCHECKBOX Other: Specify FORMTEXT ?????Other Cancer Diagnosis (DO NOT REPORT ON CURRENT LYMPHOMA DIAGNOSIS)Do you currently, or have you had another type of cancer? (NOT CURRENT LYMPHOMA DIAGNOSIS) FORMCHECKBOX No (skip to next section) FORMCHECKBOX Yes (list most recent details below)OCDAge at first diagnosis of other cancer___ ___ ___ Years oldType of Cancer Cancer type: Are you being treated for other cancer (NOT LYMPHOMA) FORMCHECKBOX No FORMCHECKBOX Yes (list treatment below)Check all that apply FORMCHECKBOX Systemic Therapy (Chemo, Hormone, Targeted Therapy) FORMCHECKBOX Surgical Resection FORMCHECKBOX Radiation FORMCHECKBOX Other, specify: FORMTEXT ?????If more than one type of cancer, complete this sectionAge at first diagnosis: ____Type of Cancer: Age at first diagnosis: ____Type of Cancer: Age at first diagnosis: ____Type of Cancer: QOL Remainder of Questionnaire.**Please respond to each item by marking one box per rowExcellentVery GoodGoodFairPoorIn general, would you say your health is:54321In general, would you say your quality of life is:54321In general, how would you rate your physical health?54321In general, how would you rate your mental health, including your mood and ability to think?54321In general, how would you rate your satisfaction with your social activities and relationships54321In general, please rate how well you carry out your usual social activities and roles. (This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc)54321CompletelyMostlyModeratelyA littleNot at allTo what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?54321In the last 7 days…NeverRarelySometimesOftenAlwaysHow often have you been bothered by emotional problems such as feeling anxious, depressed or irritable?12345NoneMildModerateSevereVery SevereHow would you rate your fatigue on average?12345NoPainWorst ImaginablePainHow would you rate your pain on average?012345678910Please circle the number (0-10) best reflecting your response to the following that describes your feelings during the past week, including today.Your Overall Quality of Life012345678910As BAD as it can beAs GOOD as it can beBelow is a list of statements that other people with your illness have said are important. By circling one (1) number per line, please indicate how true each statement has been for you during the past 7 days.PHYSICAL WELL BEINGNot at allA little bitSome whatQuite a bitVery MuchI have a lack of energy01234I have nausea01234Because of my physical condition, I have trouble meeting the needs of my family01234I have pain01234I am bothered by side effects of treatment01234I feel ill01234I am forced to spend time in bed01234SOCIAL/FAMILY WELL BEINGNot at allA little bitSome whatQuite a bitVery MuchI feel close to my friends01234I get emotional support from my family01234I get support from my friends01234My family has accepted my illness01234I am satisfied with family communication about my illness 01234I feel close to my partner (or the person who is my main support)01234Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please check this box FORMCHECKBOX and go to the next sectionI am satisfied with my sex life01234By circling one (1) number per line, please indicate how true each statement has been for you during the past 7 days.EMOTIONAL WELL BEINGNot at allA little bitSome whatQuite a bitVery MuchI feel sad01234I am satisfied with how I am coping with my illness01234I am losing hope in the fight against my illness01234I feel nervous01234I worry about dying01234I worry that my condition will get worse01234By circling one (1) number per line, please indicate how true each statement has been for you during the past 7 days.FUNCTIONAL WELL BEINGNot at allA little bitSome whatQuite a bitVery MuchI am able to work (include work at home)01234My work (include work at home) is fulfilling01234I am able to enjoy life01234I have accepted my illness01234I am sleeping well01234I am enjoying the things I usually do for fun01234I am content with the quality of my life right now01234By circling one (1) number per line, please indicate how true each statement has been for you during the past 7 days.***ADDITIONAL CONCERNSNot at allA little bitSome whatQuite a bitVery MuchI have certain parts of my body where I experience pain01234I am bothered by lumps or swelling in certain parts of my body (eg neck, armpits or groin)01234I am bothered by fevers (episodes of high body temperature)01234I have night sweats01234I am bothered by itching01234I have trouble sleeping at night01234I get tired easily01234I am losing weight01234I have a loss of appetite01234I have trouble concentrating01234I worry about getting infections01234I worry that I might get new symptoms of my illness01234I feel isolated from others because of my illness or treatment01234I have emotional ups and downs01234Because of my illness, I have difficulty planning for the future01234In general, compared to other people your age, would you say your health is: FORMCHECKBOX Poor FORMCHECKBOX Fair FORMCHECKBOX Good FORMCHECKBOX Very Good FORMCHECKBOX ExcellentHow much Difficulty, on average do you have with the following physical activities? (select one per question)No DifficultyA little DifficultySome DifficultyA Lot of DifficultyUnable to doStooping, crouching or kneeling? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lifting or carrying objects as heavy as 10 pounds? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Reaching or extending arms above shoulder level? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Writing, or handling and grasping small objects? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Walking a quarter of a mile? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Heavy housework such as scrubbing floors and washing windows? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Because of your health or a physical condition, do you have any difficulty:Shopping for personal items (like toilet items or medicine)? FORMCHECKBOX No (move to next question) FORMCHECKBOX Yes – Do you get help with shopping? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t Do – Is that because of your health? FORMCHECKBOX Yes FORMCHECKBOX NoManaging money (like keeping track of expenses or paying bills)? FORMCHECKBOX No (move to next question) FORMCHECKBOX Yes – Do you get help with managing money? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t Do – is that because of your health? FORMCHECKBOX Yes FORMCHECKBOX NoWalking across the room? USE OF CANE or WALKER IS OK FORMCHECKBOX No (move to next question) FORMCHECKBOX Yes – Do you get help with walking? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t Do – is that because of your health? FORMCHECKBOX Yes FORMCHECKBOX NoDoing light housework (like washing dishes, straightening up, or light cleaning)? FORMCHECKBOX No (move to next question) FORMCHECKBOX Yes – Do you get help with light housework? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t Do – Is that because of your health? FORMCHECKBOX Yes FORMCHECKBOX NoBathing or showering? FORMCHECKBOX No (move to next section FORMCHECKBOX Yes – Do you get help with bathing or showering? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t Do – is that because of your health? FORMCHECKBOX Yes FORMCHECKBOX No*FOOD INTAKE: As compared to my normal intake, I would rate my food intake during the past month as: FORMCHECKBOX unchanged FORMCHECKBOX more than usual FORMCHECKBOX less than usual (if checked, select answer below)I am now taking: FORMCHECKBOX normal food but less than normal amount FORMCHECKBOX little solid food FORMCHECKBOX only liquids FORMCHECKBOX only nutritional supplements FORMCHECKBOX very little of anything FORMCHECKBOX only tube feedings or only nutrition by vein*SYMPTOMS: I have had the following problems that have kept me from eating enough during the past two weeks (check all that apply) FORMCHECKBOX no problems eating FORMCHECKBOX nausea FORMCHECKBOX constipation FORMCHECKBOX mouth sores FORMCHECKBOX no appetite, just did not feel like eating FORMCHECKBOX things taste funny or have no taste FORMCHECKBOX problems swallowing FORMCHECKBOX pain: where? ______________ FORMCHECKBOX vomiting FORMCHECKBOX diarrhea FORMCHECKBOX dry mouth FORMCHECKBOX smells bother me FORMCHECKBOX feel full quickly FORMCHECKBOX fatigue FORMCHECKBOX other: ___________________(examples: depression, money, dental problems)*ACTIVITIES and FUNCTION: Over the past month, I would generally rate my activity as: FORMCHECKBOX normal with no limitations FORMCHECKBOX not my normal self, but able to be up and about with fairly normal activities FORMCHECKBOX not feeling up to most things, but in bed or chair less than half the day FORMCHECKBOX able to do little activity and spend most of the day in bed or chair FORMCHECKBOX pretty much bed ridden, rarely out of bed*Scored Patient-Generated Subjective Global Assessment (PG-SCA) ?FD Ottery 2005, 2006, 2015 v3.22.15**? 2008-2012 PROMIS Health Organization and PROMIS Cooperative Group***FACTLYM English (Universal) 16 November 2007 Copyright 1987, 1997FACTG English (Universal) 16 November 2007 Copyright 1987, 1997Vulnerable Elders Survey (VES-13) ? 2001 RThank you for taking the time to complete this form.If at any time you have questions, please contact us at: 1-800-610-7093 ................
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