ID

11404

Descrição

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

Palavras-chave

Versões (3)
  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 03/07/2015 03/07/2015 -
Transferido a

3 de julho de 2015

DOI

Para um pedido faça login.

Licença

Creative Commons BY-NC 3.0 Legacy
Comentários do modelo :

Aqui pode comentar o modelo. Pode comentá-lo especificamente através dos balões de texto nos grupos de itens e itens.

Voltar para os comentários do modelo
Comentários do grupo de itens para :

Comentários do item para :

Para descarregar formulários, precisa de ter uma sessão iniciada. Por favor faça login ou registe-se gratuitamente.

Southwest Oncology Group Medical Conditions Questionnaire

Inglês

No Instruction available.

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

SWOG clinical trial administrative data

SWOG Patient ID
Descrição

SWOGPatientID

Tipo de dados

text

SWOG Study No.
Descrição

SWOGStudyNo.

Tipo de dados

text

Registration Step
Descrição

RegistrationStep

Tipo de dados

text

Patient Initials (L, F M)
Descrição

Patient Initials

Tipo de dados

text

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

Date

Tipo de dados

date

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

MainMemberInstitution/Affiliate

Tipo de dados

text

Physician
Descrição

RegisteredInvestigator

Tipo de dados

text

Medical Conditions
Descrição

Medical Conditions

Have you ever had a heart attack?
Descrição

Haveyoueverhadaheartattack?

Tipo de dados

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.)
Descrição

Haveyoueverbeentreatedforheartfailure?

Tipo de dados

boolean

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

LowerExtremityPatientArteryBypassPersonalMedicalHistoryInd-2

Tipo de dados

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?
Descrição

HeartPatientArteryBypassPersonalMedicalHistoryInd-3

Tipo de dados

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)?
Descrição

Haveyouhadastroke,cerebrovascularaccident,bloodclotorbleedinginthebrain,ortransientischemicattack(TIA)?

Tipo de dados

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?
Descrição

Ifyouhavehadanyoftheseproblems,doyouhavedifficultymovinganarmorlegasaresultofthestrokeorcerebrovascularaccident?

Tipo de dados

boolean

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

Doyouhaveasthma?

Tipo de dados

boolean

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

Ifyouhaveasthma,doyoutakemedicinesforyourasthma?

Tipo de dados

text

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

Doyouhaveemphysema,chronicbronchitis,orchronicobstructivelungdisease?

Tipo de dados

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?
Descrição

Ifyouhaveanyoftheselungdiseases,doyoutakemedicinesforyourcondition?

Tipo de dados

text

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

Doyouhavestomachulcers,orpepticulcerdisease?

Tipo de dados

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?
Descrição

Ifyouhaveanyoftheseconditions,hasitbeendiagnosedbyadoctorlookingintoyourstomachthroughascope,orbyaskingyoutoswallowachalkydyeandthenhavingx-raystaken?

Tipo de dados

boolean

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

Doyouhavediabetes(highbloodsugar)?

Tipo de dados

boolean

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

Ifyouhavediabetes,areyoubeingtreatedforit?

Tipo de dados

text

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

Ifyouhavediabetes,hasitcausedproblemswithyourkidneys?

Tipo de dados

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?
Descrição

Ifyouhavediabetes,hasitcausedproblemswithyoureyes,treatedbyanophthalmologist?

Tipo de dados

boolean

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

Haveyoueverhadpoorkidneyfunction(bloodtestsshowhighcreatinine)?

Tipo de dados

boolean

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

Haveyouhaveusedhemodialysisorperitonealdialysis?

Tipo de dados

boolean

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

Haveyoueverreceivedakidneytransplantation?

Tipo de dados

boolean

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

Doyouhaverheumatoidarthritis?

Tipo de dados

boolean

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

Ifyouhaverheumatoidarthritis,doyoutakemedicationsforitregularly?

Tipo de dados

boolean

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

Doyouhavelupus(systemiclupuserythematosus)?

Tipo de dados

boolean

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

Doyouhavepolymyalgiarheumatica(inflammatorydisordercausingjointandmusclepain)?

Tipo de dados

boolean

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

DoyouhaveAlzheimer'sDisease,oranotherformofdementia?

Tipo de dados

boolean

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

Doyouhavecirrhosis,orseriousliverdamage?

Tipo de dados

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?
Descrição

Haveyouhadanytypeofcancer(otherthancommonskincancersuchasbasalorsquamouscellskincancer)thatwassuccessfullytreatedmorethan5yearsago?

Tipo de dados

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?
Descrição

Ifyouweretreatedforcancermorethan5yearsagohadthecancerspread,ormetastasized,tootherpartsofyourbody?

Tipo de dados

boolean

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

PatientAcquiredImmunodeficiencySyndromeAssessmentInd-3

Tipo de dados

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?
Descrição

Haveyouhadweightlossthatrequiredmedicaltreatment?

Tipo de dados

boolean

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

Ccrr Module For Southwest Oncology Group Medical Conditions Questionnaire

Voltar ao início da página

Similar models

No Instruction available.

1 Formulários
  1. StudyEvent: Southwest Oncology Group Medical Conditions Questionnaire
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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
Voltar ao início da página 

Contacto

Use este formulário para feedback, perguntas e sugestões de aperfeiçoamento.

Campos marcados com * são obrigatórios.

Ajuda

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial