ID

10037

Beschreibung

Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer NCT00024102 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A55B50C6-E69C-4D72-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A55B50C6-E69C-4D72-E034-080020C9C0E0

Stichworte

  1. 18.12.14 18.12.14 - Martin Dugas
  2. 20.03.15 20.03.15 - Martin Dugas
  3. 20.09.21 20.09.21 -
Hochgeladen am

20. März 2015

DOI

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Breast Cancer (NCT00024102)

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

Header
Beschreibung

Header

CALGB Form
Beschreibung

CALGB Form

Datentyp

text

Alias
UMLS CUI-1
C3262252
UMLS CUI-2
C1516238
CALGB Study No
Beschreibung

CALGBStudyNo

Datentyp

text

Alias
UMLS CUI-1
C3274381
UMLS CUI-2
C1516238
CALGB Patient ID
Beschreibung

CALGBPatientID

Datentyp

text

Date Completed (Medicine)
Beschreibung

DateCompleted

Datentyp

date

Amended data?
Beschreibung

Amended data?

Datentyp

boolean

Alias
UMLS CUI-1
C0680532
Patient's Name
Beschreibung

Patient'sName

Datentyp

text

Participating Group
Beschreibung

ParticipatingGroup

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Beschreibung

PatientHospitalNumber

Datentyp

text

Participating Group Protocol No.
Beschreibung

ParticipatingGroupProtocolNo.

Datentyp

text

Main Member Institution/Adjunct
Beschreibung

MainMemberInstitution/Adjunct

Datentyp

text

Participating Group Patient No.
Beschreibung

ParticipatingGroupPatientNo.

Datentyp

text

Responsible CRA
Beschreibung

ResponsibleCRA

Datentyp

text

Assessment Number (1. Your General Health)
Beschreibung

AssessmentNumber

Datentyp

float

Patient characteristics
Beschreibung

Patient characteristics

Alias
UMLS CUI-1
C0815172
Other cancers or leukemia
Beschreibung

Othercancersorleukemia

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
How much does it interfere with your activities: Other cancers or leukemia (b.)
Beschreibung

How much does it interfere with your activities: Other cancers or leukemia (b.)

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0332307
Arthritis, rheumatism, or other connective tissue disorders (b.)
Beschreibung

Arthritis,rheumatism,orotherconnectivetissuedisorders

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
How much does it interfere with your activities: Arthritis, rheumatism, or other connective tissue disorders (c.)
Beschreibung

Howmuchdoesitinterferewithyouractivities:Arthritis,rheumatism,orotherconnectivetissuedisorders

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
Glaucoma (c.)
Beschreibung

Glaucoma (c.)

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0017601
How much does it interfere with your activities: Glaucoma (d.)
Beschreibung

Howmuchdoesitinterferewithyouractivities:Glaucoma

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0332307
Emphysema or Chronic Bronchitis (d.)
Beschreibung

Emphysema or Chronic Bronchitis (d.)

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
How much does it interfere with your activities: Emphysema or Chronic Bronchitis (e.)
Beschreibung

Howmuchdoesitinterferewithyouractivities:EmphysemaorChronicBronchitis

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
High Blood Pressure (e.)
Beschreibung

HighBloodPressure

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0020538
How much does it interfere with your activities: High Blood Pressure (f.)
Beschreibung

Howmuchdoesitinterferewithyouractivities:HighBloodPressure

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
Heart disease (f.)
Beschreibung

Heartdisease

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0018799
How much does it interfere with your activities: Heart disease (g.)
Beschreibung

Howmuchdoesitinterferewithyouractivities:Heartdisease

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0332307
Circulation trouble in arms or legs (g.)
Beschreibung

Circulationtroubleinarmsorlegs

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0728936
How much does it interfere with your activities: Circulation trouble in arms or legs (h.)
Beschreibung

Howmuchdoesitinterferewithyouractivities:Circulationtroubleinarmsorlegs

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0332307
Diabetes (h.)
Beschreibung

Diabetes (h.)

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0011849
How much does it interfere with your activities: Diabetes (i.)
Beschreibung

Howmuchdoesitinterferewithyouractivities:Diabetes

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
Stomach or intestinal disorders (i.)
Beschreibung

Stomach or intestinal disorders (i.)

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
How much does it interfere with your activities: Stomach or intestinal disorders (j.)
Beschreibung

Howmuchdoesitinterferewithyouractivities:Stomachorintestinaldisorders

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
Osteoporosis (j.)
Beschreibung

Osteoporosis (j.)

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0029456
How much does it interfere with your activities: Osteoporosis (k.)
Beschreibung

Howmuchdoesitinterferewithyouractivities:Osteoporosis

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
Chronic Liver or Kidney Disease (k.)
Beschreibung

Chronic Liver or Kidney Disease (k.)

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
Beschreibung

How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
Stroke (l.)
Beschreibung

Stroke (l.)

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0038454
How much does it interfere with your activities: Stroke (m.)
Beschreibung

How much does it interfere with your activities: Stroke (m.)

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
Depression (m.)
Beschreibung

Depression (m.)

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0011581
How much does it interfere with your activities: Depression
Beschreibung

How much does it interfere with your activities: Depression

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
How is your eyesight (with glasses or contacts)? (mark one with an X)
Beschreibung

Howisyoureyesight(withglassesorcontacts)?

Datentyp

text

Alias
UMLS CUI-1
C0042812
If fair, poor or totally blind, how much does this interfere with your activities? (mark one with an X)
Beschreibung

Iffair,poorortotallyblind,howmuchdoesthisinterferewithyouractivities?

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
How is your hearing (with a hearing aid, if needed)? (mark one with an X)
Beschreibung

How is your hearing (with a hearing aid, if needed)? (mark one with an X)

Datentyp

text

Alias
UMLS CUI-1
C0018767
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
Beschreibung

If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C0332307
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
Beschreibung

Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?

Datentyp

text

Yes, specify (other physical problems or illnesses at the present time that seriously affect your health) (If Yes)
Beschreibung

Yes,specify(otherphysicalproblemsorillnessesatthepresenttimethatseriouslyaffectyourhealth)

Datentyp

text

how much does this interfere with your activities? (mark one with an X)
Beschreibung

how much does this interfere with your activities? (mark one with an X)

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
About how many times have you seen a doctor during the past 3 months, other than as an inpatient in a hospital? (6.)
Beschreibung

Abouthowmanytimeshaveyouseenadoctorduringthepast3months,otherthanasaninpatientinahospital?

Datentyp

text

During the past 3 months, how many days were you so sick that you were unable to carry out your usual activities - such as going to work or working around the house? (mark one with an X)
Beschreibung

Duringthepast3months,howmanydayswereyousosickthatyouwereunabletocarryoutyourusualactivities-suchasgoingtoworkorworkingaroundthehouse?

Datentyp

text

How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
Beschreibung

How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)

Datentyp

text

Counseling
Beschreibung

Counseling

Since you were diagnosed with cancer, have you had any treatment or counseling for personal or family problems, or for nervous or emotional problems? (8b.)
Beschreibung

Sinceyouwerediagnosedwithcancer,haveyouhadanytreatmentorcounselingforpersonalorfamilyproblems,orfornervousoremotionalproblems?

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0849496
What type of counseling or treatment did you receive? (mark all that apply with an X)
Beschreibung

What type of counseling or treatment did you receive? (mark all that apply with an X)

Datentyp

text

Other, specify (type of counseling or treatment received) (8c.)
Beschreibung

Other, specify (type of counseling or treatment received) (8c.)

Datentyp

text

Check any of these services that you are still receiving (mark all that apply with an X)
Beschreibung

Check any of these services that you are still receiving (mark all that apply with an X)

Datentyp

text

Other, specify (services that you are still receiving) (Only For ALL FOLLOW-UP INTERVIEWS: Questions 9-10)
Beschreibung

Other,specify(servicesthatyouarestillreceiving)

Datentyp

text

Have you received any counseling or treatment for personal, family or emotional problems, since that last time you were interviewed? (If Yes)
Beschreibung

Haveyoureceivedanycounselingortreatmentforpersonal,familyoremotionalproblems,sincethatlasttimeyouwereinterviewed?

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0849496
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
Beschreibung

What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)

Datentyp

text

Other, specify (services that you are still receiving; follow-up)
Beschreibung

Other,specify(servicesthatyouarestillreceiving;follow-up)

Datentyp

text

Medication
Beschreibung

Medication

Alias
UMLS CUI-1
C0013227
Medicine to treat nausea and/or vomiting
Beschreibung

Medicine to treat nausea and/or vomiting

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
Medicine to treat diarrhea
Beschreibung

Medicine to treat diarrhea

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0003292
Medicine to reduce feeling very tired [fatigue]
Beschreibung

Medicinetoreducefeelingverytired[fatigue]

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Medicine to reduce swelling in hands or feet
Beschreibung

Medicinetoreduceswellinginhandsorfeet

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Medicine or cream to treat mouth sores
Beschreibung

Medicineorcreamtotreatmouthsores

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Pain medicine for hands or feet
Beschreibung

Painmedicineforhandsorfeet

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet
Beschreibung

Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
Other, specify
Beschreibung

Other,specify

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Other, specify (medication to treat any physical problems you have had from your cancer treatment)
Beschreibung

Other,specify(medicationtotreatanyphysicalproblemsyouhavehadfromyourcancertreatment)

Datentyp

text

Arthritis medicine (If Taken, How Often?)
Beschreibung

Arthritismedicine

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Arthritis medicine (b.)
Beschreibung

If Taken, How Often: Arthritis medicine (b.)

Datentyp

text

Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
Beschreibung

Prescriptionpainkiller

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
Beschreibung

If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)

Datentyp

text

Alias
UMLS CUI-1
C0002771
UMLS CUI-2
C0439603
Over-the counter pain killers (c.)
Beschreibung

Over-thecounterpainkillers

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
Beschreibung

If Taken, How Often: Over-the counter pain killers (other than for arthritis)

Datentyp

text

High blood pressure medicine (d.)
Beschreibung

Highbloodpressuremedicine

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: High blood pressure medicine (e.)
Beschreibung

If Taken, How Often: High blood pressure medicine (e.)

Datentyp

text

Pills to make you lose water or salt (water pills or diuretics and not due to side effects from cancer treatment)
Beschreibung

Pillstomakeyoulosewaterorsalt

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Pills to make you lose water or salt (f.)
Beschreibung

If Taken, How Often: Pills to make you lose water or salt (f.)

Datentyp

text

Digoxin pills for the heart (Lanoxin)
Beschreibung

Digoxinpillsfortheheart

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
Beschreibung

If Taken, How Often: Digoxin pills for the heart (Lanoxin)

Datentyp

text

Nitroglycerin for chest pain (tablets or patches)
Beschreibung

Nitroglycerinforchestpain

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
Beschreibung

If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)

Datentyp

text

Blood thinner medicine (anticoagulants)
Beschreibung

Bloodthinnermedicine

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Blood thinner medicine (anticoagulants)
Beschreibung

If Taken, How Often: Blood thinner medicine (anticoagulants)

Datentyp

text

Medicine to improve circulation (i.)
Beschreibung

Medicinetoimprovecirculation

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Medicine to improve circulation (j.)
Beschreibung

If Taken, How Often: Medicine to improve circulation (j.)

Datentyp

text

Insulin injections for diabetes (j.)
Beschreibung

Insulin injections for diabetes (j.)

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0199782
If Taken, How Often: Insulin injections for diabetes (k.)
Beschreibung

If Taken, How Often: Insulin injections for diabetes (k.)

Datentyp

text

Pills for diabetes (k.)
Beschreibung

Pillsfordiabetes

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Pills for diabetes (l.)
Beschreibung

If Taken, How Often: Pills for diabetes (l.)

Datentyp

text

Ulcer medicine (l.)
Beschreibung

Ulcermedicine

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Ulcer medicine (m.)
Beschreibung

If Taken, How Often: Ulcer medicine (m.)

Datentyp

text

Asthma medicines (m.)
Beschreibung

Asthma medicines (m.)

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0282556
If Taken, How Often: Asthma medicines (n.)
Beschreibung

If Taken, How Often: Asthma medicines (n.)

Datentyp

text

Seizure medicines (like Dilantin)
Beschreibung

Seizuremedicines

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Seizure medicines (like Dilantin)
Beschreibung

If Taken, How Often: Seizure medicines (like Dilantin)

Datentyp

text

Thyroid pills (If Taken, How Often?)
Beschreibung

Thyroidpills

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Thyroid pills (p.)
Beschreibung

If Taken, How Often: Thyroid pills (p.)

Datentyp

text

Cortisone pills or injections (p.)
Beschreibung

Cortisonepillsorinjections

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0010137
If Taken, How Often: Cortisone pills or injections (q.)
Beschreibung

If Taken, How Often: Cortisone pills or injections (q.)

Datentyp

text

Antibiotics (q.)
Beschreibung

Antibiotics (q.)

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0003232
If Taken, How Often: Antibiotics (r.)
Beschreibung

If Taken, How Often: Antibiotics (r.)

Datentyp

text

Tranquilizers or medicine for your nerves (r.)
Beschreibung

Tranquilizersormedicineforyournerves

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0040614
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
Beschreibung

If Taken, How Often: Tranquilizers or medicine for your nerves (s.)

Datentyp

text

Prescription sleeping pills (s.)
Beschreibung

Prescriptionsleepingpills

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0599396
If Taken, How Often: Prescription sleeping pills (t.)
Beschreibung

If Taken, How Often: Prescription sleeping pills (t.)

Datentyp

text

Over-the-counter pills to help you sleep (t.)
Beschreibung

Over-the-counterpillstohelpyousleep

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
Beschreibung

If Taken, How Often: Over-the-counter pills to help you sleep (u.)

Datentyp

text

Hormones (male or female)
Beschreibung

Hormones (male or female)

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0019932
If Taken, How Often: Hormones (v.)
Beschreibung

If Taken, How Often: Hormones (v.)

Datentyp

text

Allergy medicines (v.)
Beschreibung

Allergy medicines (v.)

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0282555
If Taken, How Often: Allergy medicines (w.)
Beschreibung

If Taken, How Often: Allergy medicines (w.)

Datentyp

text

Laxatives (w.)
Beschreibung

Laxatives (w.)

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0282090
If Taken, How Often: Laxatives (x.)
Beschreibung

If Taken, How Often: Laxatives (x.)

Datentyp

text

Eye drops for glaucoma (x.)
Beschreibung

Eyedropsforglaucoma

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Eye drops for glaucoma (y.)
Beschreibung

If Taken, How Often: Eye drops for glaucoma (y.)

Datentyp

text

Calcium tablets (y.)
Beschreibung

Calciumtablets

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Calcium tablets (z.)
Beschreibung

If Taken, How Often: Calcium tablets (z.)

Datentyp

text

Vitamins and/or minerals (other than calcium)
Beschreibung

Vitaminsand/orminerals

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Taken, How Often: Vitamins and/or minerals (other than calcium)
Beschreibung

If Taken, How Often: Vitamins and/or minerals (other than calcium)

Datentyp

text

Herbal medicines (aa.)
Beschreibung

Herbalmedicines

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C0242388
If Taken, How Often: Herbal medicines (12.)
Beschreibung

If Taken, How Often: Herbal medicines (12.)

Datentyp

text

Have you taken any other medicines in the past month?
Beschreibung

Have you taken any other medicines in the past month?

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS CUI-1
C1522602
Name of Medicine
Beschreibung

NameofMedicine

Datentyp

text

If Taken, How Often?
Beschreibung

If Taken, How Often?

Datentyp

text

Alias
UMLS CUI-1
C3476109

Ähnliche Modelle

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
CALGBForm
Item
CALGB Form
text
C3262252 (UMLS CUI-1)
C1516238 (UMLS CUI-2)
CALGBStudyNo
Item
CALGB Study No
text
C3274381 (UMLS CUI-1)
C1516238 (UMLS CUI-2)
CALGBPatientID
Item
CALGB Patient ID
text
DateCompleted
Item
Date Completed (Medicine)
date
Amendeddata
Item
Amended data?
boolean
C0680532 (UMLS CUI-1)
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
ResponsibleCRA
Item
Responsible CRA
text
AssessmentNumber
Item
Assessment Number (1. Your General Health)
float
Item Group
C0815172 (UMLS CUI-1)
Other cancers or leukemia
Item
Other cancers or leukemia
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
How much does it interfere with your activities: Other cancers or leukemia (b.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS CUI-1)
Code List
How much does it interfere with your activities: Other cancers or leukemia (b.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Arthritis or rheumatism
Item
Arthritis, rheumatism, or other connective tissue disorders (b.)
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
How much does it interfere with your activities: Arthritis, rheumatism, or other connective tissue disorders (c.)
text
C25284 (NCI Thesaurus ValueDomain)
Code List
How much does it interfere with your activities: Arthritis, rheumatism, or other connective tissue disorders (c.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Glaucoma
Item
Glaucoma (c.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0017601 (UMLS CUI-1)
Item
How much does it interfere with your activities: Glaucoma (d.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS CUI-1)
Code List
How much does it interfere with your activities: Glaucoma (d.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Emphysema or ChronicBronchitis
Item
Emphysema or Chronic Bronchitis (d.)
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
How much does it interfere with your activities: Emphysema or Chronic Bronchitis (e.)
text
C25284 (NCI Thesaurus ValueDomain)
Code List
How much does it interfere with your activities: Emphysema or Chronic Bronchitis (e.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
High Blood Pressure
Item
High Blood Pressure (e.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0020538 (UMLS CUI-1)
Item
How much does it interfere with your activities: High Blood Pressure (f.)
text
C25284 (NCI Thesaurus ValueDomain)
Code List
How much does it interfere with your activities: High Blood Pressure (f.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Heartdisease
Item
Heart disease (f.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0018799 (UMLS CUI-1)
Item
How much does it interfere with your activities: Heart disease (g.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS CUI-1)
Code List
How much does it interfere with your activities: Heart disease (g.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Circulation disorder
Item
Circulation trouble in arms or legs (g.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0728936 (UMLS CUI-1)
Item
How much does it interfere with your activities: Circulation trouble in arms or legs (h.)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS CUI-1)
Code List
How much does it interfere with your activities: Circulation trouble in arms or legs (h.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Diabetes
Item
Diabetes (h.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0011849 (UMLS CUI-1)
Item
How much does it interfere with your activities: Diabetes (i.)
text
C25284 (NCI Thesaurus ValueDomain)
Code List
How much does it interfere with your activities: Diabetes (i.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Stomach or intestinal disorders
Item
Stomach or intestinal disorders (i.)
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
How much does it interfere with your activities: Stomach or intestinal disorders (j.)
text
C25284 (NCI Thesaurus ValueDomain)
Code List
How much does it interfere with your activities: Stomach or intestinal disorders (j.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Osteoporosis
Item
Osteoporosis (j.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0029456 (UMLS CUI-1)
Item
How much does it interfere with your activities: Osteoporosis (k.)
text
C25284 (NCI Thesaurus ValueDomain)
Code List
How much does it interfere with your activities: Osteoporosis (k.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Chronic Liver or Kidney Disease
Item
Chronic Liver or Kidney Disease (k.)
boolean
C25180 (NCI Thesaurus ValueDomain)
Item
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
text
C25284 (NCI Thesaurus ValueDomain)
Code List
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Stroke
Item
Stroke (l.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0038454 (UMLS CUI-1)
Item
How much does it interfere with your activities: Stroke (m.)
text
C25284 (NCI Thesaurus ValueDomain)
Code List
How much does it interfere with your activities: Stroke (m.)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Depression
Item
Depression (m.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0011581 (UMLS CUI-1)
Item
How much does it interfere with your activities: Depression
text
C25284 (NCI Thesaurus ValueDomain)
Code List
How much does it interfere with your activities: Depression
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Item
How is your eyesight (with glasses or contacts)? (mark one with an X)
text
C0042812 (UMLS CUI-1)
Code List
How is your eyesight (with glasses or contacts)? (mark one with an X)
CL Item
Excellent (Excellent)
C1961136 (UMLS CUI-1)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
C0205170 (UMLS CUI-1)
CL Item
Fair (Fair)
C2911689 (UMLS CUI-1)
CL Item
Poor (Poor)
C2700379 (UMLS CUI-1)
CL Item
Totally Blind (Totally blind)
C0456909 (UMLS CUI-1)
Item
If fair, poor or totally blind, how much does this interfere with your activities? (mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
Code List
If fair, poor or totally blind, how much does this interfere with your activities? (mark one with an X)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Item
How is your hearing (with a hearing aid, if needed)? (mark one with an X)
text
C0018767 (UMLS CUI-1)
Code List
How is your hearing (with a hearing aid, if needed)? (mark one with an X)
CL Item
Excellent (Excellent)
C1961136 (UMLS CUI-1)
CL Item
Good (Good)
C0205170 (NCI Metathesaurus)
C0205170 (UMLS CUI-1)
CL Item
Fair (Fair)
C2911689 (UMLS CUI-1)
CL Item
Poor (Poor)
C2700379 (UMLS CUI-1)
CL Item
Totally Deaf (Totally deaf)
C1547302 (UMLS CUI-1)
Item
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS CUI-1)
Code List
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Item
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
text
Code List
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Specify (Yes, specify)
Other physical problems or illnesses
Item
Yes, specify (other physical problems or illnesses at the present time that seriously affect your health) (If Yes)
text
Item
how much does this interfere with your activities? (mark one with an X)
text
C25284 (NCI Thesaurus ValueDomain)
Code List
how much does this interfere with your activities? (mark one with an X)
CL Item
Not At All (0)
C2984077 (UMLS CUI-1)
CL Item
Somewhat (1)
C2984079 (UMLS CUI-1)
CL Item
A Great Deal (2)
C2984080 (UMLS CUI-1)
Item
About how many times have you seen a doctor during the past 3 months, other than as an inpatient in a hospital? (6.)
text
Code List
About how many times have you seen a doctor during the past 3 months, other than as an inpatient in a hospital? (6.)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
1 To 2 (1 to 2)
CL Item
3 To 5 (3 to 5)
CL Item
6 To 9 (6 to 9)
CL Item
10 To 14 (10 to 14)
CL Item
15 Or More (15 or more)
CL Item
Don't Know (Don't know)
Item
During the past 3 months, how many days were you so sick that you were unable to carry out your usual activities - such as going to work or working around the house? (mark one with an X)
text
Code List
During the past 3 months, how many days were you so sick that you were unable to carry out your usual activities - such as going to work or working around the house? (mark one with an X)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
A Week Or Less (A week or less)
CL Item
More Than A Week, But Less Than A Month (More than a week, but less than a month)
CL Item
One To Two Months (One to two months)
CL Item
Three Months (Three months)
Item
How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
text
Code List
How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
1 To 2 (1 to 2)
CL Item
3 To 5 (3 to 5)
CL Item
6 To 9 (6 to 9)
CL Item
10 To 14 (10 to 14)
CL Item
15 Or More (15 or more)
CL Item
Don't Know (Don't know)
Item Group
problem related counselling
Item
Since you were diagnosed with cancer, have you had any treatment or counseling for personal or family problems, or for nervous or emotional problems? (8b.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0849496 (UMLS CUI-1)
Item
What type of counseling or treatment did you receive? (mark all that apply with an X)
text
Code List
What type of counseling or treatment did you receive? (mark all that apply with an X)
CL Item
Individual Psychotherapy (Individual Psychotherapy)
C0204525 (NCI Metathesaurus)
CL Item
Group Psychotherapy (Group Psychotherapy)
C0033971 (NCI Metathesaurus)
CL Item
Pastoral Counseling (Pastoral Counseling)
CL Item
Social Worker At Hospital (Social Worker at Hospital)
CL Item
Support Group For Cancer Patients (Support Group for Cancer Patients)
CL Item
Relaxation Training Or Hypnosis (Relaxation Training or Hypnosis)
CL Item
Other, Specify (Other, specify)
Other, specify
Item
Other, specify (type of counseling or treatment received) (8c.)
text
Item
Check any of these services that you are still receiving (mark all that apply with an X)
text
Code List
Check any of these services that you are still receiving (mark all that apply with an X)
CL Item
Individual Psychotherapy (Individual Psychotherapy)
C0204525 (NCI Metathesaurus)
CL Item
Group Psychotherapy (Group Psychotherapy)
C0033971 (NCI Metathesaurus)
CL Item
Pastoral Counseling (Pastoral Counseling)
CL Item
Social Worker At Hospital (Social Worker at Hospital)
CL Item
Support Group For Cancer Patients (Support Group for Cancer Patients)
CL Item
Relaxation Training Or Hypnosis (Relaxation Training or Hypnosis)
CL Item
Other, Specify (Other, specify)
Other,specify(servicesthatyouarestillreceiving)
Item
Other, specify (services that you are still receiving) (Only For ALL FOLLOW-UP INTERVIEWS: Questions 9-10)
text
problem related counselling
Item
Have you received any counseling or treatment for personal, family or emotional problems, since that last time you were interviewed? (If Yes)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0849496 (UMLS CUI-1)
Item
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
text
Code List
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
CL Item
Individual Psychotherapy (Individual Psychotherapy)
C0204525 (NCI Metathesaurus)
CL Item
Group Psychotherapy (Group Psychotherapy)
C0033971 (NCI Metathesaurus)
CL Item
Pastoral Counseling (Pastoral Counseling)
CL Item
Social Worker At Hospital (Social Worker at Hospital)
CL Item
Support Group For Cancer Patients (Support Group for Cancer Patients)
CL Item
Relaxation Training Or Hypnosis (Relaxation Training or Hypnosis)
CL Item
Other, Specify (Other, specify)
Other services
Item
Other, specify (services that you are still receiving; follow-up)
text
Item Group
C0013227 (UMLS CUI-1)
Medicine to treat nausea and/or vomiting
Item
Medicine to treat nausea and/or vomiting
boolean
C25180 (NCI Thesaurus ValueDomain)
Medicine to treat diarrhea
Item
Medicine to treat diarrhea
boolean
C25180 (NCI Thesaurus ValueDomain)
C0003292 (UMLS CUI-1)
Medicinetoreducefeelingverytired[fatigue]
Item
Medicine to reduce feeling very tired [fatigue]
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Medicinetoreduceswellinginhandsorfeet
Item
Medicine to reduce swelling in hands or feet
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Medicineorcreamtotreatmouthsores
Item
Medicine or cream to treat mouth sores
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Painmedicineforhandsorfeet
Item
Pain medicine for hands or feet
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Medication regarding skin changes
Item
Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet
boolean
C25180 (NCI Thesaurus ValueDomain)
Other,specify
Item
Other, specify
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Other medication
Item
Other, specify (medication to treat any physical problems you have had from your cancer treatment)
text
Arthritismedicine
Item
Arthritis medicine (If Taken, How Often?)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Arthritis medicine (b.)
text
Code List
If Taken, How Often: Arthritis medicine (b.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Prescriptionpainkiller
Item
Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
text
C0002771 (UMLS CUI-1)
C0439603 (UMLS CUI-2)
Code List
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Over-thecounterpainkillers
Item
Over-the counter pain killers (c.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
text
Code List
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Highbloodpressuremedicine
Item
High blood pressure medicine (d.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: High blood pressure medicine (e.)
text
Code List
If Taken, How Often: High blood pressure medicine (e.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Pillstomakeyoulosewaterorsalt
Item
Pills to make you lose water or salt (water pills or diuretics and not due to side effects from cancer treatment)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Pills to make you lose water or salt (f.)
text
Code List
If Taken, How Often: Pills to make you lose water or salt (f.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Digoxinpillsfortheheart
Item
Digoxin pills for the heart (Lanoxin)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
text
Code List
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Nitroglycerinforchestpain
Item
Nitroglycerin for chest pain (tablets or patches)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
text
Code List
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Bloodthinnermedicine
Item
Blood thinner medicine (anticoagulants)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Blood thinner medicine (anticoagulants)
text
Code List
If Taken, How Often: Blood thinner medicine (anticoagulants)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Medicinetoimprovecirculation
Item
Medicine to improve circulation (i.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Medicine to improve circulation (j.)
text
Code List
If Taken, How Often: Medicine to improve circulation (j.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Insulin injections for diabetes
Item
Insulin injections for diabetes (j.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0199782 (UMLS CUI-1)
Item
If Taken, How Often: Insulin injections for diabetes (k.)
text
Code List
If Taken, How Often: Insulin injections for diabetes (k.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Pillsfordiabetes
Item
Pills for diabetes (k.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Pills for diabetes (l.)
text
Code List
If Taken, How Often: Pills for diabetes (l.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Ulcermedicine
Item
Ulcer medicine (l.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Ulcer medicine (m.)
text
Code List
If Taken, How Often: Ulcer medicine (m.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Asthma medicines
Item
Asthma medicines (m.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0282556 (UMLS CUI-1)
Item
If Taken, How Often: Asthma medicines (n.)
text
Code List
If Taken, How Often: Asthma medicines (n.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Seizuremedicines
Item
Seizure medicines (like Dilantin)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Seizure medicines (like Dilantin)
text
Code List
If Taken, How Often: Seizure medicines (like Dilantin)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Thyroidpills
Item
Thyroid pills (If Taken, How Often?)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Thyroid pills (p.)
text
Code List
If Taken, How Often: Thyroid pills (p.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Cortisone
Item
Cortisone pills or injections (p.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0010137 (UMLS CUI-1)
Item
If Taken, How Often: Cortisone pills or injections (q.)
text
Code List
If Taken, How Often: Cortisone pills or injections (q.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Antibiotics
Item
Antibiotics (q.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0003232 (UMLS CUI-1)
Item
If Taken, How Often: Antibiotics (r.)
text
Code List
If Taken, How Often: Antibiotics (r.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Tranquilizer
Item
Tranquilizers or medicine for your nerves (r.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0040614 (UMLS CUI-1)
Item
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
text
Code List
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Sleeping pills
Item
Prescription sleeping pills (s.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0599396 (UMLS CUI-1)
Item
If Taken, How Often: Prescription sleeping pills (t.)
text
Code List
If Taken, How Often: Prescription sleeping pills (t.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Over-the-counterpillstohelpyousleep
Item
Over-the-counter pills to help you sleep (t.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
text
Code List
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Hormones
Item
Hormones (male or female)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0019932 (UMLS CUI-1)
Item
If Taken, How Often: Hormones (v.)
text
Code List
If Taken, How Often: Hormones (v.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Allergy medicines
Item
Allergy medicines (v.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0282555 (UMLS CUI-1)
Item
If Taken, How Often: Allergy medicines (w.)
text
Code List
If Taken, How Often: Allergy medicines (w.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Laxatives
Item
Laxatives (w.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0282090 (UMLS CUI-1)
Item
If Taken, How Often: Laxatives (x.)
text
Code List
If Taken, How Often: Laxatives (x.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Eyedropsforglaucoma
Item
Eye drops for glaucoma (x.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Eye drops for glaucoma (y.)
text
Code List
If Taken, How Often: Eye drops for glaucoma (y.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Calciumtablets
Item
Calcium tablets (y.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Calcium tablets (z.)
text
Code List
If Taken, How Often: Calcium tablets (z.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Vitaminsand/orminerals
Item
Vitamins and/or minerals (other than calcium)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If Taken, How Often: Vitamins and/or minerals (other than calcium)
text
Code List
If Taken, How Often: Vitamins and/or minerals (other than calcium)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
Herbal medicine
Item
Herbal medicines (aa.)
boolean
C25180 (NCI Thesaurus ValueDomain)
C0242388 (UMLS CUI-1)
Item
If Taken, How Often: Herbal medicines (12.)
text
Code List
If Taken, How Often: Herbal medicines (12.)
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)
other medication past month
Item
Have you taken any other medicines in the past month?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS CUI-1)
NameofMedicine
Item
Name of Medicine
text
Item
If Taken, How Often?
text
C3476109 (UMLS CUI-1)
Code List
If Taken, How Often?
CL Item
Once A Day (Once a Day)
C0556983 (UMLS CUI-1)
CL Item
More Than Once A Day (More than Once a Day)
C3853132 (UMLS CUI-1)
CL Item
Take As Needed (Take As Needed)
C1883728 (UMLS CUI-1)

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