ID
1170
Beskrivning
NSABP-B-47 Medical Conditions and Lifestyle Questionnaire Form - Baseline (Form MCL-B) A Randomized Phase III Trial of Adjuvant Therapy Comparing Chemotherapy Alone (Six Cycles of Docetaxel Plus Cyclophosphamide or Four Cycles of Doxorubicin Plus Cyclophosphamide Followed by Weekly Paclitaxel) to Chemotherapy Plus Trastuzumab in Women With Node- Positive or High-Risk Node-Negative HER2-Low Invasive Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=96C1751F-BCDC-2B10-E040-BB89AD433A9B
Länk
Nyckelord
Versioner (5)
- 2012-08-27 2012-08-27 -
- 2014-08-11 2014-08-11 - Martin Dugas
- 2014-08-11 2014-08-11 - Martin Dugas
- 2014-08-11 2014-08-11 - Martin Dugas
- 2015-01-09 2015-01-09 - Martin Dugas
Uppladdad den
27 augusti 2012
DOI
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Licens
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT01275677 Quality of Life - NSABP-B-47 Medical Conditions and Lifestyle Questionnaire Form - Baseline (Form MCL-B) - 3165170v1.0
INSTRUCTIONS TO THE INSTITUTION This questionnaire should be completed by all patients. This form should be completed after the patient has signed the B-47 consent forms, but before randomization. A clinical staff member should complete page 1, print the patient's initials at the top of Pages 2 through 5, and give the questionnaire to the patient for completion. After the patient has completed the questionnaire, verify that the date the questionnaire was completed is recorded at the top of page 2. After the patient has been randomized, print the NSABP Patient ID at the top of pages 2 through 5 and fax all 5 pages to the NSABP Biostatistical Center at (412) 622-2115
- StudyEvent: NSABP-B-47 Medical Conditions and Lifestyle Questionnaire Form - Baseline (Form MCL-B)
Beskrivning
Time Point
Beskrivning
CaseReportFormPersonCompleteType
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus Property
- C25190
- UMLS 2011AA Property
- C0027361
- NCI Thesaurus ObjectClass
- C40988
- UMLS 2011AA ObjectClass
- C1516308
- NCI Thesaurus Property
- C25250
- UMLS 2011AA Property
- C0205197
Beskrivning
QualityofLifeCompleteAssessmentDate
Datatyp
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ObjectClass
- C17047
- UMLS 2011AA ObjectClass
- C0518214
- NCI Thesaurus Property
- C25250
- UMLS 2011AA Property
- C0205197
- NCI Thesaurus Property
- C25367
Beskrivning
Section 1 - Lifetime Medical Conditions
Beskrivning
ChronicDiseasePresentType
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus Property
- C25626
- UMLS 2011AA Property
- C0150312
- NCI Thesaurus ObjectClass
- C2991
- UMLS 2011AA ObjectClass
- C0012634
- NCI Thesaurus ObjectClass
- C14141
- UMLS 2011AA ObjectClass
- C0205191
Beskrivning
DiseaseorDisorderPhysicianCareAssessmentAssessmentInd-3
Datatyp
text
Alias
- NCI Thesaurus ObjectClass
- C2991
- UMLS 2011AA ObjectClass
- C0012634
- NCI Thesaurus Property
- C25741
- UMLS 2011AA Property
- C0031831
- NCI Thesaurus Property
- C25217
- UMLS 2011AA Property
- C1516048
- NCI Thesaurus Property
- C61488
- UMLS 2011AA Property
- C1947933
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
Beskrivning
PatientMedicalConditionTherapyInd-2
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25261
- UMLS 2011AA Property
- C0205476
- NCI Thesaurus Property
- C25457
- UMLS 2011AA Property
- C0348080
Beskrivning
PersonDiseaseorDisorderActivityRestrictionAssessmentInd-3
Datatyp
text
Alias
- NCI Thesaurus ObjectClass
- C25190
- UMLS 2011AA ObjectClass
- C0027361
- NCI Thesaurus Property
- C25367
- NCI Thesaurus Property
- C43431
- UMLS 2011AA Property
- C0441655
- NCI Thesaurus Property
- C2991
- UMLS 2011AA Property
- C0012634
- NCI Thesaurus Property
- C53452
- UMLS 2011AA Property
- C0443288
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
Beskrivning
Section 2 - Tobacco Usage
Beskrivning
SmokingHistoryIndicator
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
- NCI Thesaurus ObjectClass
- C17934
- UMLS 2011AA ObjectClass
- C0453996
- NCI Thesaurus Property
- C18772
- UMLS 2011AA Property
- C0262926
Beskrivning
Tobaccootheruseindicator
Datatyp
text
Alias
- NCI Thesaurus ObjectClass
- C17649
- UMLS 2011AA ObjectClass
- C0205394
- NCI Thesaurus ObjectClass
- C891
- UMLS 2011AA ObjectClass
- C0040329
- NCI Thesaurus ObjectClass
- C691
- UMLS 2011AA ObjectClass
- C0028040
- NCI Thesaurus Property
- C25340
- UMLS 2011AA Property
- C0457083
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
OtherTobaccoUseType
Datatyp
text
Alias
- NCI Thesaurus Property
- C25284
- UMLS 2011AA Property
- C0332307
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus ObjectClass
- C891
- UMLS 2011AA ObjectClass
- C0040329
Beskrivning
PatientInitialCigaretteSmokingAgeYearCount
Datatyp
double
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25536
- UMLS 2011AA Property
- C1555582
- NCI Thesaurus Property
- C18270
- UMLS 2011AA Property
- C0700219
- NCI Thesaurus ValueDomain
- C29848
- UMLS 2011AA ValueDomain
- C0439234
- NCI Thesaurus ValueDomain
- C25463
- UMLS 2011AA ValueDomain
- C0750480
Beskrivning
SmokingHistoryType
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus ObjectClass
- C17934
- UMLS 2011AA ObjectClass
- C0453996
- NCI Thesaurus Property
- C18772
- UMLS 2011AA Property
- C0262926
Beskrivning
CurrentSmokingHistoryType
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus ObjectClass
- C25471
- UMLS 2011AA ObjectClass
- C0521116
- NCI Thesaurus ObjectClass
- C17934
- UMLS 2011AA ObjectClass
- C0453996
- NCI Thesaurus Property
- C18772
- UMLS 2011AA Property
- C0262926
Beskrivning
SmokingCurrentUseDailyFrequency
Datatyp
text
Alias
- NCI Thesaurus ObjectClass
- C17934
- UMLS 2011AA ObjectClass
- C0453996
- NCI Thesaurus Property
- C25471
- UMLS 2011AA Property
- C0521116
- NCI Metathesaurus Property
- C0449865
- NCI Thesaurus ValueDomain
- C25473
- UMLS 2011AA ValueDomain
- C0332173
- NCI Thesaurus ValueDomain
- C25515
- UMLS 2011AA ValueDomain
- C0439603
Beskrivning
Section 3 - Alcohol Consumption
Beskrivning
AlcoholLifetimeHistoryIndicator
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
- NCI Thesaurus Property
- C18772
- UMLS 2011AA Property
- C0262926
- NCI Thesaurus ObjectClass
- C2190
- UMLS 2011AA ObjectClass
- C0001962
Beskrivning
AlcoholUseLifetimeInd
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
- NCI Thesaurus ObjectClass
- C2190
- UMLS 2011AA ObjectClass
- C0001962
- NCI Thesaurus Property
- C25340
- UMLS 2011AA Property
- C0457083
Beskrivning
AlcoholConsumptionPastYearIndicator
Datatyp
text
Alias
- NCI Thesaurus ObjectClass
- C2190
- UMLS 2011AA ObjectClass
- C0001962
- NCI Thesaurus Property
- C29848
- UMLS 2011AA Property
- C0439234
- NCI Thesaurus Property
- C25340
- UMLS 2011AA Property
- C0457083
- NCI Thesaurus Property
- C25609
- UMLS 2011AA Property
- C1444637
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beskrivning
AlcoholCurrentUseRangeType
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus Property
- C25471
- UMLS 2011AA Property
- C0521116
- NCI Thesaurus ObjectClass
- C2190
- UMLS 2011AA ObjectClass
- C0001962
- NCI Thesaurus Property
- C25340
- UMLS 2011AA Property
- C0457083
Beskrivning
AlcoholAverageDailyUseType
Datatyp
text
Alias
- NCI Thesaurus ObjectClass
- C2190
- UMLS 2011AA ObjectClass
- C0001962
- NCI Thesaurus Property
- C25473
- UMLS 2011AA Property
- C0332173
- NCI Thesaurus Property
- C37917
- UMLS 2011AA Property
- C1510992
- NCI Thesaurus Property
- C25340
- UMLS 2011AA Property
- C0457083
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
Beskrivning
AlcoholDrinkUseWeekNumber
Datatyp
double
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS 2011AA ValueDomain
- C0237753
- NCI Thesaurus Property
- C25471
- UMLS 2011AA Property
- C0521116
- NCI Thesaurus ObjectClass
- C2190
- UMLS 2011AA ObjectClass
- C0001962
- NCI Thesaurus Property
- C25340
- UMLS 2011AA Property
- C0457083
Similar models
INSTRUCTIONS TO THE INSTITUTION This questionnaire should be completed by all patients. This form should be completed after the patient has signed the B-47 consent forms, but before randomization. A clinical staff member should complete page 1, print the patient's initials at the top of Pages 2 through 5, and give the questionnaire to the patient for completion. After the patient has completed the questionnaire, verify that the date the questionnaire was completed is recorded at the top of page 2. After the patient has been randomized, print the NSABP Patient ID at the top of pages 2 through 5 and fax all 5 pages to the NSABP Biostatistical Center at (412) 622-2115
- StudyEvent: NSABP-B-47 Medical Conditions and Lifestyle Questionnaire Form - Baseline (Form MCL-B)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C15818 (NCI Thesaurus Property)
C1513905 (UMLS 2011AA Property)
C0205195 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25551 (NCI Thesaurus ValueDomain)
C1517741 (UMLS 2011AA ValueDomain)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25509 (NCI Thesaurus ValueDomain)
C1279901 (UMLS 2011AA ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C0205394 (UMLS 2011AA)
C0011008 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C0332307 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C14141 (NCI Thesaurus ObjectClass)
C0205191 (UMLS 2011AA ObjectClass)
C0006826 (UMLS 2011AA)
C0018802 (UMLS 2011AA)
C0011570 (UMLS 2011AA)
C0011849 (UMLS 2011AA)
C0010068 (UMLS 2011AA)
C0022646 (UMLS 2011AA)
C2991 (NCI Thesaurus)
C0012634 (UMLS 2011AA)
C0023884 (UMLS 2011AA)
C2991 (NCI Thesaurus)
C0012634 (UMLS 2011AA)
C2709248 (UMLS 2011AA)
C2991 (NCI Thesaurus)
C0012634 (UMLS 2011AA)
C0029408 (UMLS 2011AA)
C0003811 (UMLS 2011AA)
C0003873 (UMLS 2011AA)
C0040132 (UMLS 2011AA)
C2991 (NCI Thesaurus)
C0012634 (UMLS 2011AA)
C0041582 (UMLS 2011AA)
C0012634 (UMLS 2011AA ObjectClass)
C25741 (NCI Thesaurus Property)
C0031831 (UMLS 2011AA Property)
C25217 (NCI Thesaurus Property)
C1516048 (UMLS 2011AA Property)
C61488 (NCI Thesaurus Property)
C1947933 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25261 (NCI Thesaurus Property)
C0205476 (UMLS 2011AA Property)
C25457 (NCI Thesaurus Property)
C0348080 (UMLS 2011AA Property)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0027361 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C43431 (NCI Thesaurus Property)
C0441655 (UMLS 2011AA Property)
C2991 (NCI Thesaurus Property)
C0012634 (UMLS 2011AA Property)
C53452 (NCI Thesaurus Property)
C0443288 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C0205394 (UMLS 2011AA ObjectClass)
C891 (NCI Thesaurus ObjectClass)
C0040329 (UMLS 2011AA ObjectClass)
C691 (NCI Thesaurus ObjectClass)
C0028040 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C0332307 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C891 (NCI Thesaurus ObjectClass)
C0040329 (UMLS 2011AA ObjectClass)
C0182504 (UMLS 2011AA)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C18270 (NCI Thesaurus Property)
C0700219 (UMLS 2011AA Property)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C0332307 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus ObjectClass)
C0521116 (UMLS 2011AA ObjectClass)
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C0453996 (UMLS 2011AA ObjectClass)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C0449865 (NCI Metathesaurus Property)
C25473 (NCI Thesaurus ValueDomain)
C0332173 (UMLS 2011AA ValueDomain)
C25515 (NCI Thesaurus ValueDomain)
C0439603 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C0001962 (UMLS 2011AA ObjectClass)
C29848 (NCI Thesaurus Property)
C0439234 (UMLS 2011AA Property)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C25609 (NCI Thesaurus Property)
C1444637 (UMLS 2011AA Property)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C0332307 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C0001962 (UMLS 2011AA ObjectClass)
C25473 (NCI Thesaurus Property)
C0332173 (UMLS 2011AA Property)
C37917 (NCI Thesaurus Property)
C1510992 (UMLS 2011AA Property)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)