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11601

Description

AMC-045 Complete Physical Exam Form (F21) Cisplatin, Fluorouracil, Cetuximab, and Radiation Therapy in Treating Patients With HIV and Stage I, Stage II, or Stage III Anal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4428A103-FC35-0EB3-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4428A103-FC35-0EB3-E044-0003BA3F9857

Keywords

Versions (3)
  1. 8/26/12 8/26/12 -
  2. 7/8/15 7/8/15 -
  3. 7/8/15 7/8/15 -
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July 8, 2015

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Creative Commons BY-NC 3.0 Legacy
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    AMC-045 Complete Physical Exam Form (F21)

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: AMC-045 Complete Physical Exam Form (F21)
      1. No Instruction available.
    Header Module
    Description

    Header Module

    Visit number
    Description

    HospitalAdmissionOrdinalNumber

    Data type

    double

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16696
    UMLS 2011AA ObjectClass
    C0019994
    NCI Thesaurus Property
    C25385
    UMLS 2011AA Property
    C0809949
    Date of evaluation (mm/dd/yyyy)
    Description

    AssessmentPerformedDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25367
    NCI Thesaurus ValueDomain
    C25367
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    Physical Exam
    Description

    Physical Exam

    Primary site
    Description

    PatientCompletePhysicalExaminationAnatomicSite

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus Property
    C25421
    UMLS 2011AA Property
    C0002808
    NCI Thesaurus ValueDomain
    C37901
    UMLS 2011AA ValueDomain
    C0205145
    Other, specify
    Description

    PatientCompletePhysicalExaminationAnatomicLocationSpecify

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus Property
    C25421
    UMLS 2011AA Property
    C0002808
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Assessment
    Description

    PatientCompletePhysicalExaminationStatus

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus ValueDomain
    C25688
    UMLS 2011AA ValueDomain
    C0449438
    Describe abnormal findings
    Description

    PatientAbnormalPhysicalExaminationSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus Property
    C25401
    UMLS 2011AA Property
    C0205161
    Comments
    Description

    Comments

    Comments
    Description

    ResearchCommentsText

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    UMLS 2011AA Property
    C0282411
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    Similar models

    No Instruction available.

    1 forms
    1. StudyEvent: AMC-045 Complete Physical Exam Form (F21)
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header Module
    HospitalAdmissionOrdinalNumber
    Item
    Visit number
    double
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16696 (NCI Thesaurus ObjectClass)
    C0019994 (UMLS 2011AA ObjectClass)
    C25385 (NCI Thesaurus Property)
    C0809949 (UMLS 2011AA Property)
    AssessmentPerformedDate
    Item
    Date of evaluation (mm/dd/yyyy)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ObjectClass)
    C25367 (NCI Thesaurus ValueDomain)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    Item Group
    Physical Exam
    Item
    Primary site
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C25421 (NCI Thesaurus Property)
    C0002808 (UMLS 2011AA Property)
    C37901 (NCI Thesaurus ValueDomain)
    C0205145 (UMLS 2011AA ValueDomain)
    CL.1
    Code List
    Primary site
    CL Item
    Skin (Skin)
    C12470 (NCI Thesaurus)
    C1123023 (UMLS 2011AA)
    CL Item
    Lymph Node (Lymph Nodes)
    C12745 (NCI Thesaurus)
    C0024204 (UMLS 2011AA)
    CL Item
    Head (Head)
    C12419 (NCI Thesaurus)
    C0018670 (UMLS 2011AA)
    CL Item
    Eye (Eyes)
    C12401 (NCI Thesaurus)
    C0015392 (UMLS 2011AA)
    CL Item
    Ear (Ears)
    C12394 (NCI Thesaurus)
    C0013443 (UMLS 2011AA)
    CL Item
    Mouth (Mouth)
    C0922752 (NCI Metathesaurus)
    CL Item
    Neck (Neck)
    C13063 (NCI Thesaurus)
    C0027530 (UMLS 2011AA)
    CL Item
    Chest (Chest)
    C25389 (NCI Thesaurus)
    C0817096 (UMLS 2011AA)
    CL Item
    Heart (Heart)
    C12727 (NCI Thesaurus)
    C0018787 (UMLS 2011AA)
    CL Item
    Lung (Lungs)
    C12468 (NCI Thesaurus)
    C0024109 (UMLS 2011AA)
    CL Item
    Abdomen (Abdomen)
    C12664 (NCI Thesaurus)
    C0230168 (UMLS 2011AA)
    CL Item
    Liver (Liver)
    C12392 (NCI Thesaurus)
    C0023884 (UMLS 2011AA)
    CL Item
    Spleen (Spleen)
    C12432 (NCI Thesaurus)
    C0037993 (UMLS 2011AA)
    CL Item
    Genitalia (Genital)
    C25177 (NCI Thesaurus)
    C0017420 (UMLS 2011AA)
    CL Item
    Rectal (Rectal)
    C25224 (NCI Thesaurus)
    C0205052 (UMLS 2011AA)
    CL Item
    Extremities (Extremities)
    C30140 (NCI Thesaurus)
    CL Item
    Neurologic (Neurological)
    C25262 (NCI Thesaurus)
    C0205494 (UMLS 2011AA)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    PatientCompletePhysicalExaminationAnatomicLocationSpecify
    Item
    Other, specify
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C25421 (NCI Thesaurus Property)
    C0002808 (UMLS 2011AA Property)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Item
    Assessment
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25688 (NCI Thesaurus ValueDomain)
    C0449438 (UMLS 2011AA ValueDomain)
    CL.2
    Code List
    Assessment
    CL Item
    Normal (Normal)
    C14165 (NCI Thesaurus)
    C0205307 (UMLS 2011AA)
    CL Item
    Abnormal (Abnormal)
    C25401 (NCI Thesaurus)
    C0205161 (UMLS 2011AA)
    CL Item
    Not Evaluated (Not Evaluated)
    PatientAbnormalPhysicalExaminationSpecify
    Item
    Describe abnormal findings
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C25401 (NCI Thesaurus Property)
    C0205161 (UMLS 2011AA Property)
    Item Group
    Comments
    ResearchCommentsText
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    C0282411 (UMLS 2011AA Property)
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