ID

10293

Description

FACT-B (Version 4), E2100 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC2FF0E4-063C-2184-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AC2FF0E4-063C-2184-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/27/12 8/27/12 -
  2. 5/23/15 5/23/15 -
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May 23, 2015

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Creative Commons BY-NC 3.0 Legacy
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FACT-B (Version 4), E2100

English

Form No. 1576

1 forms  
  1. StudyEvent: FACT-B (Version 4), E2100
    1. Form No. 1576
ECOG clinical trial administrative data
Description

ECOG clinical trial administrative data

ECOG Protocol No.
Description

ECOGProtocolNo.

Data type

text

ECOG Patient ID (B1)
Description

ECOGPatientID

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain-2
C16154
UMLS 2011AA ValueDomain-2
C1704379
Date of assessment
Description

Dateofassessment

Data type

text

Patient's Name
Description

Patient'sName

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Participating Group Patient ID
Description

ParticipatingGroupPatientID

Data type

text

Institution/Affiliate (GP1)
Description

MainMemberInstitution/Affiliate

Data type

text

Physical Well-being
Description

Physical Well-being

I have a lack of energy (GP2)
Description

PatientEnergyAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C48058
UMLS 2011AA Property-2
C0542479
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I have nausea (GP3)
Description

PatientNauseaAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C3258
UMLS 2011AA Property-2
C0027497
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
Because of my physical condition, I have trouble meeting the needs of my family (GP4)
Description

PatientGeneralPhysicalConditionAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
CL104641
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I have pain (GP5)
Description

PatientPainAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C3303
UMLS 2011AA Property-2
C0030193
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I am bothered by side effects of treatment (GP6)
Description

PatientAdverseEventAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C41331
UMLS 2011AA Property-2
C0877248
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I feel ill (GP7)
Description

PatientMalaiseAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property-2
C3832
UMLS 2011AA Property-2
C0231218
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I am forced to spend time in bed (GS1)
Description

PatientBedRestAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
Social/family Well-being
Description

Social/family Well-being

I feel close to my friends (GS2)
Description

Ifeelclosetomyfriends

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
I get emotional support from my family (GS3)
Description

Igetemotionalsupportfrommyfamily

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
I get support from my friends (GS4)
Description

Igetsupportfrommyfriends

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
My family has accepted my illness (GS5)
Description

Myfamilyhasacceptedmyillness

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
I am satisfied with communication about my illness (GS6)
Description

Iamsatisfiedwithfamilycommunicationaboutmyillness

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
I feel close to my partner (or the person who is my main support)
Description

Ifeelclosetomypartner(orthepersonwhoismymainsupport)

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
(Prefer not to answer next question) (Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please check this box and go to the next section.)
Description

(Prefernottoanswernextquestion)

Data type

text

I am satisfied with my sex life.
Description

Iamsatisfiedwithmysexlife

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Emotional Well-being
Description

Emotional Well-being

I feel sad (GE2)
Description

Ifeelsad

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
I am satisfied with how I am coping with my illness (GE3)
Description

IamsatisfiedwithhowIamcopingwithmyillness

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
I am losing hope in the fight against my illness (GE4)
Description

Iamlosinghopeinthefightagainstmyillness

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
I feel nervous (GE5)
Description

Ifeelnervous

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
I worry about dying (GE6)
Description

Iworryaboutdying

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
I worry that my condition will get worse (GF1)
Description

Iworrythatmyconditionwillgetworse

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Functional Well-being
Description

Functional Well-being

I am able to work (include work at home) (GF2)
Description

AbilityPatientWorkAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus ObjectClass
C0085732
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0043227
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
My work (include work at home) is fulfilling (GF3)
Description

SatisfactionPatientWorkAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25367
NCI Thesaurus Property-2
C62185
UMLS 2011AA Property
C0242428
NCI Metathesaurus Property
C0043227
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I am able to enjoy life (GF4)
Description

PatientEnjoymentofLifeAssessmentQualityofLifeAssessment

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
CL196329
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I have accepted my illness (GF5)
Description

Ihaveacceptedmyillness

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I am sleeping well (GF6)
Description

Iamsleepingwell

Data type

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I am enjoying things I usually do for fun (GF7)
Description

PleasurePatientRecreationAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus ObjectClass
C0679105
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0034872
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I am content with the quality of my life right now
Description

PatientQualityofLifeAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C17047
UMLS 2011AA Property
C0518214
NCI Thesaurus Property-2
C20989
UMLS 2011AA Property-2
C0031809
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
Additional Concerns
Description

Additional Concerns

I have been short of breath (B2)
Description

QualityofLifeDyspneaEvaluationScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C25214
UMLS 2011AA Property
C0220825
NCI Thesaurus Property-2
C2998
UMLS 2011AA Property-2
C0013404
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain-2
C17047
UMLS 2011AA ValueDomain-2
C0518214
I am self-concious about the way I dress (B3)
Description

Iamself-conciousaboutthewayIdress

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
One or both of my arms are swollen and tender (B4)
Description

Oneorbothofmyarmsareswollenandtender

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
I feel sexually attractive (B5)
Description

Ifeelsexuallyattractive

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
I am bothered by my hair loss (B6)
Description

Iambotheredbymyhairloss

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
I worry that other members of my family might someday get the same illness I have (B7)
Description

IworrythatothermembersofmyfamilymightsomedaygetthesameillnessIhave

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
I worry about the effects of stress on my illness (B8)
Description

Iworryabouttheeffectsofstressonmyillness

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
I am bothered by a change in weight (B9)
Description

Iambotheredbyachangeinweight

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
I am able to feel like a woman
Description

Iamabletofeellikeawoman

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Ccrr Module For Fact-b (version 4), E2100
Description

Ccrr Module For Fact-b (version 4), E2100

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Form No. 1576

1 forms
  1. StudyEvent: FACT-B (Version 4), E2100
    1. Form No. 1576
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
ECOG clinical trial administrative data
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID (B1)
text
RegistrationStep
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16154 (NCI Thesaurus ValueDomain-2)
C1704379 (UMLS 2011AA ValueDomain-2)
Dateofassessment
Item
Date of assessment
text
Patient'sName
Item
Patient's Name
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate (GP1)
text
Item Group
Physical Well-being
Item
I have a lack of energy (GP2)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C48058 (NCI Thesaurus Property-2)
C0542479 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.1
Code List
I have a lack of energy (GP2)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I have nausea (GP3)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3258 (NCI Thesaurus Property-2)
C0027497 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.2
Code List
I have nausea (GP3)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
Because of my physical condition, I have trouble meeting the needs of my family (GP4)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL104641 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.3
Code List
Because of my physical condition, I have trouble meeting the needs of my family (GP4)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I have pain (GP5)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3303 (NCI Thesaurus Property-2)
C0030193 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.4
Code List
I have pain (GP5)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I am bothered by side effects of treatment (GP6)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C41331 (NCI Thesaurus Property-2)
C0877248 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.5
Code List
I am bothered by side effects of treatment (GP6)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I feel ill (GP7)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3832 (NCI Thesaurus Property-2)
C0231218 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.6
Code List
I feel ill (GP7)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I am forced to spend time in bed (GS1)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL.7
Code List
I am forced to spend time in bed (GS1)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item Group
Social/family Well-being
Item
I feel close to my friends (GS2)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.8
Code List
I feel close to my friends (GS2)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I get emotional support from my family (GS3)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.9
Code List
I get emotional support from my family (GS3)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I get support from my friends (GS4)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.10
Code List
I get support from my friends (GS4)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
My family has accepted my illness (GS5)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.11
Code List
My family has accepted my illness (GS5)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I am satisfied with communication about my illness (GS6)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.12
Code List
I am satisfied with communication about my illness (GS6)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I feel close to my partner (or the person who is my main support)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.13
Code List
I feel close to my partner (or the person who is my main support)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
(Prefernottoanswernextquestion)
Item
(Prefer not to answer next question) (Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please check this box and go to the next section.)
text
Item
I am satisfied with my sex life.
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.14
Code List
I am satisfied with my sex life.
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item Group
Emotional Well-being
Item
I feel sad (GE2)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.15
Code List
I feel sad (GE2)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I am satisfied with how I am coping with my illness (GE3)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.16
Code List
I am satisfied with how I am coping with my illness (GE3)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I am losing hope in the fight against my illness (GE4)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.17
Code List
I am losing hope in the fight against my illness (GE4)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I feel nervous (GE5)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.18
Code List
I feel nervous (GE5)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I worry about dying (GE6)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.19
Code List
I worry about dying (GE6)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I worry that my condition will get worse (GF1)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.20
Code List
I worry that my condition will get worse (GF1)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item Group
Functional Well-being
Item
I am able to work (include work at home) (GF2)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0085732 (NCI Metathesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0043227 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.21
Code List
I am able to work (include work at home) (GF2)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
My work (include work at home) is fulfilling (GF3)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C62185 (NCI Thesaurus Property-2)
C0242428 (UMLS 2011AA Property)
C0043227 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.22
Code List
My work (include work at home) is fulfilling (GF3)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I am able to enjoy life (GF4)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL196329 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.23
Code List
I am able to enjoy life (GF4)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I have accepted my illness (GF5)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.24
Code List
I have accepted my illness (GF5)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I am sleeping well (GF6)
text
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.25
Code List
I am sleeping well (GF6)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I am enjoying things I usually do for fun (GF7)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0679105 (NCI Metathesaurus ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0034872 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.26
Code List
I am enjoying things I usually do for fun (GF7)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I am content with the quality of my life right now
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17047 (NCI Thesaurus Property)
C0518214 (UMLS 2011AA Property)
C20989 (NCI Thesaurus Property-2)
C0031809 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.27
Code List
I am content with the quality of my life right now
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item Group
Additional Concerns
Item
I have been short of breath (B2)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C2998 (NCI Thesaurus Property-2)
C0013404 (UMLS 2011AA Property-2)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain-2)
C0518214 (UMLS 2011AA ValueDomain-2)
CL.28
Code List
I have been short of breath (B2)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus-2)
C70543 (NCI Thesaurus-3)
C2003901 (UMLS 2011AA)
CL Item
A Little Bit (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus-2)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus-2)
Item
I am self-concious about the way I dress (B3)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.29
Code List
I am self-concious about the way I dress (B3)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
One or both of my arms are swollen and tender (B4)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.30
Code List
One or both of my arms are swollen and tender (B4)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I feel sexually attractive (B5)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.31
Code List
I feel sexually attractive (B5)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I am bothered by my hair loss (B6)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.32
Code List
I am bothered by my hair loss (B6)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I worry that other members of my family might someday get the same illness I have (B7)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.33
Code List
I worry that other members of my family might someday get the same illness I have (B7)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I worry about the effects of stress on my illness (B8)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.34
Code List
I worry about the effects of stress on my illness (B8)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I am bothered by a change in weight (B9)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.35
Code List
I am bothered by a change in weight (B9)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item
I am able to feel like a woman
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.36
Code List
I am able to feel like a woman
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
CL Item
A Little (A little bit)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
Item Group
Ccrr Module For Fact-b (version 4), E2100
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