ID
10037
Description
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
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Mots-clés
Versions (3)
- 18/12/2014 18/12/2014 - Martin Dugas
- 20/03/2015 20/03/2015 - Martin Dugas
- 20/09/2021 20/09/2021 -
Téléchargé le
20 mars 2015
DOI
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Creative Commons BY-NC 3.0 Legacy
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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.
Description
Patient characteristics
Alias
- UMLS CUI-1
- C0815172
Description
Othercancersorleukemia
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Description
How much does it interfere with your activities: Other cancers or leukemia (b.)
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Description
Arthritis,rheumatism,orotherconnectivetissuedisorders
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Description
Howmuchdoesitinterferewithyouractivities:Arthritis,rheumatism,orotherconnectivetissuedisorders
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Description
Glaucoma (c.)
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0017601
Description
Howmuchdoesitinterferewithyouractivities:Glaucoma
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Description
Emphysema or Chronic Bronchitis (d.)
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Description
Howmuchdoesitinterferewithyouractivities:EmphysemaorChronicBronchitis
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Description
HighBloodPressure
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0020538
Description
Howmuchdoesitinterferewithyouractivities:HighBloodPressure
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Description
Heartdisease
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0018799
Description
Howmuchdoesitinterferewithyouractivities:Heartdisease
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Description
Circulationtroubleinarmsorlegs
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0728936
Description
Howmuchdoesitinterferewithyouractivities:Circulationtroubleinarmsorlegs
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Description
Diabetes (h.)
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0011849
Description
Howmuchdoesitinterferewithyouractivities:Diabetes
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Description
Stomach or intestinal disorders (i.)
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Description
Howmuchdoesitinterferewithyouractivities:Stomachorintestinaldisorders
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Description
Osteoporosis (j.)
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0029456
Description
Howmuchdoesitinterferewithyouractivities:Osteoporosis
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Description
Chronic Liver or Kidney Disease (k.)
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Description
How much does it interfere with your activities: Chronic Liver or Kidney Disease (l.)
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Description
Stroke (l.)
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0038454
Description
How much does it interfere with your activities: Stroke (m.)
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Description
Depression (m.)
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0011581
Description
How much does it interfere with your activities: Depression
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Description
Howisyoureyesight(withglassesorcontacts)?
Type de données
text
Alias
- UMLS CUI-1
- C0042812
Description
Iffair,poorortotallyblind,howmuchdoesthisinterferewithyouractivities?
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Description
How is your hearing (with a hearing aid, if needed)? (mark one with an X)
Type de données
text
Alias
- UMLS CUI-1
- C0018767
Description
If fair, poor or totally deaf, how much does this interfere with your activities? (mark one with an X)
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C0332307
Description
Do you have any other physical problems or illnesses (than listed in question 1-3) at the present time that seriously affect your health?
Type de données
text
Description
Yes,specify(otherphysicalproblemsorillnessesatthepresenttimethatseriouslyaffectyourhealth)
Type de données
text
Description
how much does this interfere with your activities? (mark one with an X)
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
Description
Abouthowmanytimeshaveyouseenadoctorduringthepast3months,otherthanasaninpatientinahospital?
Type de données
text
Description
Duringthepast3months,howmanydayswereyousosickthatyouwereunabletocarryoutyourusualactivities-suchasgoingtoworkorworkingaroundthehouse?
Type de données
text
Description
How many days in the past 3 months were you in a hospital for physical health problems? (mark one with an X)
Type de données
text
Description
Counseling
Description
Sinceyouwerediagnosedwithcancer,haveyouhadanytreatmentorcounselingforpersonalorfamilyproblems,orfornervousoremotionalproblems?
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0849496
Description
What type of counseling or treatment did you receive? (mark all that apply with an X)
Type de données
text
Description
Other, specify (type of counseling or treatment received) (8c.)
Type de données
text
Description
Check any of these services that you are still receiving (mark all that apply with an X)
Type de données
text
Description
Other,specify(servicesthatyouarestillreceiving)
Type de données
text
Description
Haveyoureceivedanycounselingortreatmentforpersonal,familyoremotionalproblems,sincethatlasttimeyouwereinterviewed?
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0849496
Description
What type of counseling or treatment did you receive? (follow-up) (mark all that apply with an X)
Type de données
text
Description
Other,specify(servicesthatyouarestillreceiving;follow-up)
Type de données
text
Description
Medication
Alias
- UMLS CUI-1
- C0013227
Description
Medicine to treat nausea and/or vomiting
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Description
Medicine to treat diarrhea
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0003292
Description
Medicinetoreducefeelingverytired[fatigue]
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Medicinetoreduceswellinginhandsorfeet
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Medicineorcreamtotreatmouthsores
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Painmedicineforhandsorfeet
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Medicine or cream to treat skin changes (e.g. redness, peeling) in hands or feet
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Description
Other,specify
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Other,specify(medicationtotreatanyphysicalproblemsyouhavehadfromyourcancertreatment)
Type de données
text
Description
Arthritismedicine
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Arthritis medicine (b.)
Type de données
text
Description
Prescriptionpainkiller
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Prescription pain killer (other than for arthritis and not due to side effects from cancer treatment)
Type de données
text
Alias
- UMLS CUI-1
- C0002771
- UMLS CUI-2
- C0439603
Description
Over-thecounterpainkillers
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Over-the counter pain killers (other than for arthritis)
Type de données
text
Description
Highbloodpressuremedicine
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: High blood pressure medicine (e.)
Type de données
text
Description
Pillstomakeyoulosewaterorsalt
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Pills to make you lose water or salt (f.)
Type de données
text
Description
Digoxinpillsfortheheart
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Digoxin pills for the heart (Lanoxin)
Type de données
text
Description
Nitroglycerinforchestpain
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Nitroglycerin for chest pain (tablets or patches)
Type de données
text
Description
Bloodthinnermedicine
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Blood thinner medicine (anticoagulants)
Type de données
text
Description
Medicinetoimprovecirculation
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Medicine to improve circulation (j.)
Type de données
text
Description
Insulin injections for diabetes (j.)
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0199782
Description
If Taken, How Often: Insulin injections for diabetes (k.)
Type de données
text
Description
Pillsfordiabetes
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Pills for diabetes (l.)
Type de données
text
Description
Ulcermedicine
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Ulcer medicine (m.)
Type de données
text
Description
Asthma medicines (m.)
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0282556
Description
If Taken, How Often: Asthma medicines (n.)
Type de données
text
Description
Seizuremedicines
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Seizure medicines (like Dilantin)
Type de données
text
Description
Thyroidpills
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Thyroid pills (p.)
Type de données
text
Description
Cortisonepillsorinjections
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0010137
Description
If Taken, How Often: Cortisone pills or injections (q.)
Type de données
text
Description
Antibiotics (q.)
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0003232
Description
If Taken, How Often: Antibiotics (r.)
Type de données
text
Description
Tranquilizersormedicineforyournerves
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0040614
Description
If Taken, How Often: Tranquilizers or medicine for your nerves (s.)
Type de données
text
Description
Prescriptionsleepingpills
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0599396
Description
If Taken, How Often: Prescription sleeping pills (t.)
Type de données
text
Description
Over-the-counterpillstohelpyousleep
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Over-the-counter pills to help you sleep (u.)
Type de données
text
Description
Hormones (male or female)
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0019932
Description
If Taken, How Often: Hormones (v.)
Type de données
text
Description
Allergy medicines (v.)
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0282555
Description
If Taken, How Often: Allergy medicines (w.)
Type de données
text
Description
Laxatives (w.)
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0282090
Description
If Taken, How Often: Laxatives (x.)
Type de données
text
Description
Eyedropsforglaucoma
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Eye drops for glaucoma (y.)
Type de données
text
Description
Calciumtablets
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Calcium tablets (z.)
Type de données
text
Description
Vitaminsand/orminerals
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
If Taken, How Often: Vitamins and/or minerals (other than calcium)
Type de données
text
Description
Herbalmedicines
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C0242388
Description
If Taken, How Often: Herbal medicines (12.)
Type de données
text
Description
Have you taken any other medicines in the past month?
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C1522602
Description
NameofMedicine
Type de données
text
Description
If Taken, How Often?
Type de données
text
Alias
- UMLS CUI-1
- C3476109
Similar models
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.
C1516238 (UMLS CUI-2)
C1516238 (UMLS CUI-2)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0332307 (UMLS CUI-1)
C0017601 (UMLS CUI-1)
C0332307 (UMLS CUI-1)
C0020538 (UMLS CUI-1)
C0018799 (UMLS CUI-1)
C0332307 (UMLS CUI-1)
C0728936 (UMLS CUI-1)
C0332307 (UMLS CUI-1)
C0011849 (UMLS CUI-1)
C0029456 (UMLS CUI-1)
C0038454 (UMLS CUI-1)
C0011581 (UMLS CUI-1)
C0205170 (UMLS CUI-1)
C0205170 (UMLS CUI-1)
C0332307 (UMLS CUI-1)
C1298908 (UMLS 2011AA)
C0549184 (UMLS 2011AA)
C0549184 (UMLS 2011AA)
C0549184 (UMLS 2011AA)
C0849496 (UMLS CUI-1)
C0849496 (UMLS CUI-1)
C0003292 (UMLS CUI-1)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0439603 (UMLS CUI-2)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0199782 (UMLS CUI-1)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0282556 (UMLS CUI-1)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0010137 (UMLS CUI-1)
C0003232 (UMLS CUI-1)
C0040614 (UMLS CUI-1)
C0599396 (UMLS CUI-1)
C1522602 (UMLS 2011AA ValueDomain)
C0019932 (UMLS CUI-1)
C0282555 (UMLS CUI-1)
C0282090 (UMLS CUI-1)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0242388 (UMLS CUI-1)
C1522602 (UMLS CUI-1)