ID

11404

Beschrijving

Southwest Oncology Group Medical Conditions Questionnaire Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CF6FCD-888E-36E1-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CF6FCD-888E-36E1-E034-080020C9C0E0

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 03-07-15 03-07-15 -
Geüploaded op

3 juli 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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Southwest Oncology Group Medical Conditions Questionnaire

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: Southwest Oncology Group Medical Conditions Questionnaire
    1. No Instruction available.
SWOG clinical trial administrative data
Beschrijving

SWOG clinical trial administrative data

SWOG Patient ID
Beschrijving

SWOGPatientID

Datatype

text

SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Registration Step
Beschrijving

RegistrationStep

Datatype

text

Patient Initials (L, F M)
Beschrijving

Patient Initials

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Date
Beschrijving

Date

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Institution/Affiliate
Beschrijving

MainMemberInstitution/Affiliate

Datatype

text

Physician
Beschrijving

RegisteredInvestigator

Datatype

text

Medical Conditions
Beschrijving

Medical Conditions

Have you ever had a heart attack?
Beschrijving

Haveyoueverhadaheartattack?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Have you ever been treated for heart failure? (You may have been short of breath and the doctor may have told you that you had fluid in your lungs or that your heart was not pumping well.)
Beschrijving

Haveyoueverbeentreatedforheartfailure?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Have you had an operation to unclog or bypass the arteries in your legs?
Beschrijving

LowerExtremityPatientArteryBypassPersonalMedicalHistoryInd-2

Datatype

boolean

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus ObjectClass
C0023216
NCI Thesaurus Property
C12372
UMLS 2011AA Property
C0003842
NCI Thesaurus Property-2
C18772
UMLS 2011AA Property-2
C0262926
NCI Thesaurus Property-3
C15723
UMLS 2011AA Property-3
C0741847
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Have you had an operation or procedure to unclog or bypass the arteries in your heart?
Beschrijving

HeartPatientArteryBypassPersonalMedicalHistoryInd-3

Datatype

boolean

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass-2
C12727
UMLS 2011AA ObjectClass-2
C0018787
NCI Thesaurus Property
C12372
UMLS 2011AA Property
C0003842
NCI Thesaurus Property-2
C18772
UMLS 2011AA Property-2
C0262926
NCI Thesaurus Property-3
C15723
UMLS 2011AA Property-3
C0741847
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Have you had a stroke, cerebrovascular accident, blood clot or bleeding in the brain, or transient ischemic attack (TIA)?
Beschrijving

Haveyouhadastroke,cerebrovascularaccident,bloodclotorbleedinginthebrain,ortransientischemicattack(TIA)?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If you have had any of these problems, do you have difficulty moving an arm or leg as a result of the stroke or cerebrovascular accident?
Beschrijving

Ifyouhavehadanyoftheseproblems,doyouhavedifficultymovinganarmorlegasaresultofthestrokeorcerebrovascularaccident?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Do you have asthma?
Beschrijving

Doyouhaveasthma?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If you have asthma, do you take medicines for your asthma?
Beschrijving

Ifyouhaveasthma,doyoutakemedicinesforyourasthma?

Datatype

text

Do you have emphysema, chronic bronchitis, or chronic obstructive lung disease?
Beschrijving

Doyouhaveemphysema,chronicbronchitis,orchronicobstructivelungdisease?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If you have any of these lung diseases, do you take medicines for your condition?
Beschrijving

Ifyouhaveanyoftheselungdiseases,doyoutakemedicinesforyourcondition?

Datatype

text

Do you have stomach ulcers, or peptic ulcer disease?
Beschrijving

Doyouhavestomachulcers,orpepticulcerdisease?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus Property-2
C25757
UMLS 2011AA Property-2
C0041582
If you have any of these conditions, has it been diagnosed by a doctor looking into your stomach through a scope, or by asking you to swallow a chalky dye and then having x-rays taken?
Beschrijving

Ifyouhaveanyoftheseconditions,hasitbeendiagnosedbyadoctorlookingintoyourstomachthroughascope,orbyaskingyoutoswallowachalkydyeandthenhavingx-raystaken?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Do you have diabetes (high blood sugar)?
Beschrijving

Doyouhavediabetes(highbloodsugar)?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If you have diabetes, are you being treated for it?
Beschrijving

Ifyouhavediabetes,areyoubeingtreatedforit?

Datatype

text

If you have diabetes, has it caused problems with your kidneys?
Beschrijving

Ifyouhavediabetes,hasitcausedproblemswithyourkidneys?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If you have diabetes, has it caused problems with your eyes, treated by an ophthalmologist?
Beschrijving

Ifyouhavediabetes,hasitcausedproblemswithyoureyes,treatedbyanophthalmologist?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Have you ever had poor kidney function (blood tests show high creatinine)?
Beschrijving

Haveyoueverhadpoorkidneyfunction(bloodtestsshowhighcreatinine)?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Have you have used hemodialysis or peritoneal dialysis?
Beschrijving

Haveyouhaveusedhemodialysisorperitonealdialysis?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Have you ever received a kidney transplantation?
Beschrijving

Haveyoueverreceivedakidneytransplantation?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Do you have rheumatoid arthritis?
Beschrijving

Doyouhaverheumatoidarthritis?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If you have rheumatoid arthritis, do you take medications for it regularly?
Beschrijving

Ifyouhaverheumatoidarthritis,doyoutakemedicationsforitregularly?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Do you have lupus (systemic lupus erythematosus)?
Beschrijving

Doyouhavelupus(systemiclupuserythematosus)?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Do you have polymyalgia rheumatica (inflammatory disorder causing joint and muscle pain)?
Beschrijving

Doyouhavepolymyalgiarheumatica(inflammatorydisordercausingjointandmusclepain)?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Do you have Alzheimer's Disease, or another form of dementia?
Beschrijving

DoyouhaveAlzheimer'sDisease,oranotherformofdementia?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Do you have cirrhosis, or serious liver damage?
Beschrijving

Doyouhavecirrhosis,orseriousliverdamage?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Have you had any type of cancer (other than common skin cancer such as basal or squamous cell skin cancer) that was successfully treated more than 5 years ago?
Beschrijving

Haveyouhadanytypeofcancer(otherthancommonskincancersuchasbasalorsquamouscellskincancer)thatwassuccessfullytreatedmorethan5yearsago?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If you were treated for cancer more than 5 years ago had the cancer spread, or metastasized, to other parts of your body?
Beschrijving

Ifyouweretreatedforcancermorethan5yearsagohadthecancerspread,ormetastasized,tootherpartsofyourbody?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Do you have AIDS (acquired immunodeficiency syndrome)?
Beschrijving

PatientAcquiredImmunodeficiencySyndromeAssessmentInd-3

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C2851
UMLS 2011AA Property-2
C0001175
Have you had weight loss that required medical treatment?
Beschrijving

Haveyouhadweightlossthatrequiredmedicaltreatment?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Ccrr Module For Southwest Oncology Group Medical Conditions Questionnaire
Beschrijving

Ccrr Module For Southwest Oncology Group Medical Conditions Questionnaire

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: Southwest Oncology Group Medical Conditions Questionnaire
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
SWOG clinical trial administrative data
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
Patient Initials
Item
Patient Initials (L, F M)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
RegisteredInvestigator
Item
Physician
text
Item Group
Medical Conditions
Haveyoueverhadaheartattack?
Item
Have you ever had a heart attack?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Haveyoueverbeentreatedforheartfailure?
Item
Have you ever been treated for heart failure? (You may have been short of breath and the doctor may have told you that you had fluid in your lungs or that your heart was not pumping well.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
LowerExtremityPatientArteryBypassPersonalMedicalHistoryInd-2
Item
Have you had an operation to unclog or bypass the arteries in your legs?
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0023216 (NCI Metathesaurus ObjectClass)
C12372 (NCI Thesaurus Property)
C0003842 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
C15723 (NCI Thesaurus Property-3)
C0741847 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
HeartPatientArteryBypassPersonalMedicalHistoryInd-3
Item
Have you had an operation or procedure to unclog or bypass the arteries in your heart?
boolean
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12727 (NCI Thesaurus ObjectClass-2)
C0018787 (UMLS 2011AA ObjectClass-2)
C12372 (NCI Thesaurus Property)
C0003842 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property-2)
C0262926 (UMLS 2011AA Property-2)
C15723 (NCI Thesaurus Property-3)
C0741847 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Haveyouhadastroke,cerebrovascularaccident,bloodclotorbleedinginthebrain,ortransientischemicattack(TIA)?
Item
Have you had a stroke, cerebrovascular accident, blood clot or bleeding in the brain, or transient ischemic attack (TIA)?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Ifyouhavehadanyoftheseproblems,doyouhavedifficultymovinganarmorlegasaresultofthestrokeorcerebrovascularaccident?
Item
If you have had any of these problems, do you have difficulty moving an arm or leg as a result of the stroke or cerebrovascular accident?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Doyouhaveasthma?
Item
Do you have asthma?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If you have asthma, do you take medicines for your asthma?
text
CL.8
Code List
If you have asthma, do you take medicines for your asthma?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Only With Flare-ups Of My Asthma (Yes, only with flare-ups of my asthma)
CL Item
Yes, I Take Medicines Regularly, Even When I'm Not Having A Flare-up (Yes, I take medicines regularly, even when I'm not having a flare-up)
Doyouhaveemphysema,chronicbronchitis,orchronicobstructivelungdisease?
Item
Do you have emphysema, chronic bronchitis, or chronic obstructive lung disease?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If you have any of these lung diseases, do you take medicines for your condition?
text
CL.10
Code List
If you have any of these lung diseases, do you take medicines for your condition?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Only With Flare-ups Of My Asthma (Yes, only with flare-ups of my asthma)
CL Item
Yes, I Take Medicines Regularly, Even When I'm Not Having A Flare-up (Yes, I take medicines regularly, even when I'm not having a flare-up)
Doyouhavestomachulcers,orpepticulcerdisease?
Item
Do you have stomach ulcers, or peptic ulcer disease?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C25757 (NCI Thesaurus Property-2)
C0041582 (UMLS 2011AA Property-2)
Ifyouhaveanyoftheseconditions,hasitbeendiagnosedbyadoctorlookingintoyourstomachthroughascope,orbyaskingyoutoswallowachalkydyeandthenhavingx-raystaken?
Item
If you have any of these conditions, has it been diagnosed by a doctor looking into your stomach through a scope, or by asking you to swallow a chalky dye and then having x-rays taken?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Doyouhavediabetes(highbloodsugar)?
Item
Do you have diabetes (high blood sugar)?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If you have diabetes, are you being treated for it?
text
CL.14
Code List
If you have diabetes, are you being treated for it?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Treated By Modifying My Diet (Yes, treated by modifying my diet)
CL Item
Yes, Treated By Medications Taken By Mouth (Yes, treated by medications taken by mouth)
CL Item
Yes, Treated By Insuling Injections (Yes, treated by insuling injections)
Ifyouhavediabetes,hasitcausedproblemswithyourkidneys?
Item
If you have diabetes, has it caused problems with your kidneys?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Ifyouhavediabetes,hasitcausedproblemswithyoureyes,treatedbyanophthalmologist?
Item
If you have diabetes, has it caused problems with your eyes, treated by an ophthalmologist?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Haveyoueverhadpoorkidneyfunction(bloodtestsshowhighcreatinine)?
Item
Have you ever had poor kidney function (blood tests show high creatinine)?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Haveyouhaveusedhemodialysisorperitonealdialysis?
Item
Have you have used hemodialysis or peritoneal dialysis?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Haveyoueverreceivedakidneytransplantation?
Item
Have you ever received a kidney transplantation?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Doyouhaverheumatoidarthritis?
Item
Do you have rheumatoid arthritis?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Ifyouhaverheumatoidarthritis,doyoutakemedicationsforitregularly?
Item
If you have rheumatoid arthritis, do you take medications for it regularly?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Doyouhavelupus(systemiclupuserythematosus)?
Item
Do you have lupus (systemic lupus erythematosus)?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Doyouhavepolymyalgiarheumatica(inflammatorydisordercausingjointandmusclepain)?
Item
Do you have polymyalgia rheumatica (inflammatory disorder causing joint and muscle pain)?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
DoyouhaveAlzheimer'sDisease,oranotherformofdementia?
Item
Do you have Alzheimer's Disease, or another form of dementia?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Doyouhavecirrhosis,orseriousliverdamage?
Item
Do you have cirrhosis, or serious liver damage?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Haveyouhadanytypeofcancer(otherthancommonskincancersuchasbasalorsquamouscellskincancer)thatwassuccessfullytreatedmorethan5yearsago?
Item
Have you had any type of cancer (other than common skin cancer such as basal or squamous cell skin cancer) that was successfully treated more than 5 years ago?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Ifyouweretreatedforcancermorethan5yearsagohadthecancerspread,ormetastasized,tootherpartsofyourbody?
Item
If you were treated for cancer more than 5 years ago had the cancer spread, or metastasized, to other parts of your body?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
PatientAcquiredImmunodeficiencySyndromeAssessmentInd-3
Item
Do you have AIDS (acquired immunodeficiency syndrome)?
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C2851 (NCI Thesaurus Property-2)
C0001175 (UMLS 2011AA Property-2)
Haveyouhadweightlossthatrequiredmedicaltreatment?
Item
Have you had weight loss that required medical treatment?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item Group
Ccrr Module For Southwest Oncology Group Medical Conditions Questionnaire
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