-ANZMTG XX.XX[Trial Name]Trial-

-Follow Up Cost Questionnaire Form: FORM FU-CQPage 1 of 3-

Date form completed//

  1. Since your last study visit, did your disease and/or Yes No N/A

treatment stop you from working?

Tick N/A if not in the workforce

If Yes please indicate the number of days unable to work

  1. Since your last study visit, did your disease and/or treatment Yes No

stop you from performing your usual activities?

If Yesplease indicate the number of days affected and specifySpecify |______|

the types of activities that were unable to be performed|______|

  1. Have you visited a health professional (related to your melanoma groin diagnosis) since your previous study visit?

Health Professional / Yes / No / Total No.
of Visits / MBS Code(s)
OFFICE USE ONLY
General practitioner clinic visit / / /
General practitioner home visit / / /
General practitioner telephone consultation / / /
Physiotherapist / / /
Lymphoedema therapist / / /
Dietician / / /
Social worker / / /
Psychologist / / /
Other, please specify |______| / / /
  1. Have you visited a cancer specialist (related to your melanoma groin metastases diagnosis) since your previous study visit?

Cancer Specialist / Yes / No / Total No.
of Visits / MBS Code(s)
OFFICE USE ONLY
Radiation oncologist / / /
Medical oncologist / / /
Surgical oncologist / / /
Palliative care professional / / /
Other, please specify |______| / / /


  1. In relation to your melanoma diagnosis, did any of your visits to a health Yes No

professional and/or a cancer specialist require a procedure to be performed?

If Yes please complete No 4

If No please skip No 4

  1. Please indicate the procedure(s) and the number of times these were performed

Procedure
Enter Y / N (Do not leave boxes blank) / No. of TimesPerformed / MBS Code(s)
OFFICE USE ONLY / Procedure
Enter Y / N (Do not leave boxes blank) / No. of TimesPerformed / MBS Code(s)
OFFICE USE ONLY
Day surgery, specify / / Cytology/Pathology /
|______| / e.g. biopsy, FNA etc.
Mutation testing / / Blood test /
PET/CT scan / / Bone scan /
MRI scan / / CT scan /
Specify anatomical site of scan / Specify anatomical site of scan
|______| / |______|
X-ray / / Ultrasound /
Specify anatomical site of scan / Specify anatomical site of scan
|______| / |______|
Targeted therapy / / Immunotherapy /
Radiotherapy / / SRS /
Other, specify / / Other, specify /
|______| / |______|
  1. Enter the number of inpatient hospitalisations related to the diagnosis of

melanoma groin metastases since the previous study visit (enter 0 if none)

  1. If the patient had one or more inpatient hospitalisations since the previous study visit, please complete the table below

Inpatient Visit / No. of Nights
(Length of Stay) / Reason(s) for Visit / DRG Code(s) (if known)
OFFICE USE ONLY / DRG Code(s)
OFFICE USE ONLY
1 /
2 /
3 /
4 /
5 /
6 /


  1. What is your current work status?

Full-time paid work (include self-employed) Part time paid work

Specify average hours per week

Unemployed looking for work Not in the workforce

Sick leave

Indicate type Paid Unpaid

  1. We would like to know how your disease and treatment impacts you financially over time. The average household income in Australia is $1,234 per week. What was the total weekly income before tax of all members of our household aged 15 years or over? Please include all income from wages, self-employment, investments, pensions and benefits.

Less than $617 per week Unsure

Between $618 and $1,234 per week

Between $1,235 and $2,467 per week

More than $2,468 per week

  1. What is your main source of income? (please tick one only)

Wage/salaries Government benefits

Self-employed No source

Spouse/partner Other, please specify |______|

ANZMTG XX.XX [Trial Name] Follow Up Cost Questionnaire Form [Version: vX.X] – [Date Form Created: DD/MM/YYYY]