ID

11404

Description

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

Link

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

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/3/15 7/3/15 -
Uploaded on

July 3, 2015

DOI

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License

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

English

No Instruction available.

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

SWOG clinical trial administrative data

SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Patient Initials (L, F M)
Description

Patient Initials

Data type

text

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

Date

Data type

date

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

MainMemberInstitution/Affiliate

Data type

text

Physician
Description

RegisteredInvestigator

Data type

text

Medical Conditions
Description

Medical Conditions

Have you ever had a heart attack?
Description

Haveyoueverhadaheartattack?

Data type

boolean

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

Haveyoueverbeentreatedforheartfailure?

Data type

boolean

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

LowerExtremityPatientArteryBypassPersonalMedicalHistoryInd-2

Data type

boolean

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

HeartPatientArteryBypassPersonalMedicalHistoryInd-3

Data type

boolean

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

Haveyouhadastroke,cerebrovascularaccident,bloodclotorbleedinginthebrain,ortransientischemicattack(TIA)?

Data type

boolean

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

Ifyouhavehadanyoftheseproblems,doyouhavedifficultymovinganarmorlegasaresultofthestrokeorcerebrovascularaccident?

Data type

boolean

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

Doyouhaveasthma?

Data type

boolean

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

Ifyouhaveasthma,doyoutakemedicinesforyourasthma?

Data type

text

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

Doyouhaveemphysema,chronicbronchitis,orchronicobstructivelungdisease?

Data type

boolean

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

Ifyouhaveanyoftheselungdiseases,doyoutakemedicinesforyourcondition?

Data type

text

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

Doyouhavestomachulcers,orpepticulcerdisease?

Data type

boolean

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

Ifyouhaveanyoftheseconditions,hasitbeendiagnosedbyadoctorlookingintoyourstomachthroughascope,orbyaskingyoutoswallowachalkydyeandthenhavingx-raystaken?

Data type

boolean

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

Doyouhavediabetes(highbloodsugar)?

Data type

boolean

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

Ifyouhavediabetes,areyoubeingtreatedforit?

Data type

text

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

Ifyouhavediabetes,hasitcausedproblemswithyourkidneys?

Data type

boolean

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

Ifyouhavediabetes,hasitcausedproblemswithyoureyes,treatedbyanophthalmologist?

Data type

boolean

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

Haveyoueverhadpoorkidneyfunction(bloodtestsshowhighcreatinine)?

Data type

boolean

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

Haveyouhaveusedhemodialysisorperitonealdialysis?

Data type

boolean

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

Haveyoueverreceivedakidneytransplantation?

Data type

boolean

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

Doyouhaverheumatoidarthritis?

Data type

boolean

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

Ifyouhaverheumatoidarthritis,doyoutakemedicationsforitregularly?

Data type

boolean

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

Doyouhavelupus(systemiclupuserythematosus)?

Data type

boolean

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

Doyouhavepolymyalgiarheumatica(inflammatorydisordercausingjointandmusclepain)?

Data type

boolean

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

DoyouhaveAlzheimer'sDisease,oranotherformofdementia?

Data type

boolean

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

Doyouhavecirrhosis,orseriousliverdamage?

Data type

boolean

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

Haveyouhadanytypeofcancer(otherthancommonskincancersuchasbasalorsquamouscellskincancer)thatwassuccessfullytreatedmorethan5yearsago?

Data type

boolean

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

Ifyouweretreatedforcancermorethan5yearsagohadthecancerspread,ormetastasized,tootherpartsofyourbody?

Data type

boolean

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

PatientAcquiredImmunodeficiencySyndromeAssessmentInd-3

Data type

boolean

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

Haveyouhadweightlossthatrequiredmedicaltreatment?

Data type

boolean

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

Ccrr Module For Southwest Oncology Group Medical Conditions Questionnaire

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Similar models

No Instruction available.

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