ID

11767

Beschrijving

ODM form derived from Humangenetik Senologie UKM. Used as a routine documentation by the University Hospital Muenster, Germany.

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Versies (1)
  1. 30-07-15 30-07-15 -
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30 juli 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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Checklist for genetic disposition breast cancer and/or Ovarian cancer

Duits ( localization.languageCode.DE ) Engels

Checklist for genetic disposition breast cancer and/or Ovarian cancer

1 Formulieren  
Patient demographics
Beschrijving

Patient demographics

Date of birth
Beschrijving

Date of birth

Datatype

date

Case #
Beschrijving

Case #

Datatype

integer

Gender
Beschrijving

Gender

Datatype

text

Alias
UMLS CUI-1
C0079399
Stationary admission
Beschrijving

Stationary admission

Datatype

text

Registration date
Beschrijving

Registration date

Datatype

date

Registered by
Beschrijving

Registered by

Datatype

text

A. Patient and her siblings / children
Beschrijving

A. Patient and her siblings / children

Breast cancer prior to the age of 36
Beschrijving

Breast cancer prior to the age of 36

Datatype

integer

Alias
UMLS CUI-1
C0678222
Unilateral breast canster prior to the age of 51
Beschrijving

Unilateral breast canster prior to the age of 51

Datatype

integer

Bilateral breast canster prior to the age of 51
Beschrijving

Bilateral breast canster prior to the age of 51

Datatype

integer

Alias
UMLS CUI-1
C0238767
UMLS CUI-2
C0007104
Unilateral or Bilateral breast canster after the age of 50
Beschrijving

Unilateral or Bilateral breast canster after the age of 50

Datatype

integer

Alias
UMLS CUI-1
C0238767
UMLS CUI-2
C0007104
Ovarian cancer or a primary peritonitis carcinomatosa
Beschrijving

Ovarian cancer or a primary peritonitis carcinomatosa

Datatype

integer

Alias
UMLS CUI-1
C1611183
UMLS CUI-2
C0029925
Sister/daughter has breast cancer prior to the age of 36
Beschrijving

Sister/daughter has breast cancer prior to the age of 36

Datatype

integer

Sisiter/ daughter has unilateral breast canster prior to the age of 51
Beschrijving

Sisiter/ daughter has unilateral breast canster prior to the age of 51

Datatype

integer

Sister/ daughter has bilateral breast canster prior to the age of 51
Beschrijving

Sister/ daughter has bilateral breast canster prior to the age of 51

Datatype

integer

Sister/ daughter has unilateral or blateral breast canster after the age of 50
Beschrijving

Sister/ daughter has unilateral or blateral breast canster after the age of 50

Datatype

integer

Brother/ son has breast cancer
Beschrijving

Brother/ son has breast cancer

Datatype

integer

Sister/ daughter has ovarian cancer or a primary peritonitis carcinomatosa
Beschrijving

Sister/ daughter has ovarian cancer or a primary peritonitis carcinomatosa

Datatype

integer

Total
Beschrijving

Total

Datatype

integer

B. Matrilineality
Beschrijving

B. Matrilineality

Relatuve has breast cancer prior to the age of 36
Beschrijving

Relatuve has breast cancer prior to the age of 36

Datatype

integer

Relative has unilateral breast canster prior to the age of 51
Beschrijving

Relative has unilateral breast canster prior to the age of 51

Datatype

integer

Relative has bilateral breast canster prior to the age of 51
Beschrijving

Relative has bilateral breast canster prior to the age of 51

Datatype

integer

Relative has unilateral or blateral breast canster after the age of 50
Beschrijving

Relative has unilateral or blateral breast canster after the age of 50

Datatype

integer

Male relative has breast cancer
Beschrijving

Male relative has breast cancer

Datatype

integer

Relative has ovarian cancer or a primary peritonitis carcinomatosa
Beschrijving

Relative has ovarian cancer or a primary peritonitis carcinomatosa

Datatype

integer

Total
Beschrijving

Total

Datatype

integer

Patrilineality
Beschrijving

Patrilineality

Relative has breast cancer prior to the age of 36
Beschrijving

Relative has breast cancer prior to the age of 36

Datatype

integer

Relative has unilateral breast canster prior to the age of 51
Beschrijving

Relative has unilateral breast canster prior to the age of 51

Datatype

integer

Relative has bilateral breast canster prior to the age of 51
Beschrijving

Relative has bilateral breast canster prior to the age of 51

Datatype

integer

Relative has unilateral or blateral breast canster after the age of 50
Beschrijving

Relative has unilateral or blateral breast canster after the age of 50

Datatype

integer

Male relative has breast cancer
Beschrijving

Male relative has breast cancer

Datatype

integer

Relative has ovarian cancer or a primary peritonitis carcinomatosa
Beschrijving

Relative has ovarian cancer or a primary peritonitis carcinomatosa

Datatype

integer

Total
Beschrijving

Total

Datatype

integer

D. Higher score B. matrilineality or C. patrilineality
Beschrijving

D. Higher score B. matrilineality or C. patrilineality

E. Total A+D
Beschrijving

E. Total A+D

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Similar models

Checklist for genetic disposition breast cancer and/or Ovarian cancer

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Patient demographics
Date of birth
Item
Date of birth
date
Case #
Item
Case #
integer
Gender
Item
Gender
text
C0079399 (UMLS CUI-1)
Stationary admission
Item
Stationary admission
text
Registration date
Item
Registration date
date
Registered by
Item
Registered by
text
Item Group
A. Patient and her siblings / children
Item
Breast cancer prior to the age of 36
integer
C0678222 (UMLS CUI-1)
Breast cancer
Code List
Breast cancer prior to the age of 36
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Unilateral breast canster prior to the age of 51
integer
Breast cancer
Code List
Unilateral breast canster prior to the age of 51
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Bilateral breast canster prior to the age of 51
integer
C0238767 (UMLS CUI-1)
C0007104 (UMLS CUI-2)
Breast cancer
Code List
Bilateral breast canster prior to the age of 51
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Unilateral or Bilateral breast canster after the age of 50
integer
C0238767 (UMLS CUI-1)
C0007104 (UMLS CUI-2)
Breast cancer
Code List
Unilateral or Bilateral breast canster after the age of 50
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Ovarian cancer or a primary peritonitis carcinomatosa
integer
C1611183 (UMLS CUI-1)
C0029925 (UMLS CUI-2)
Breast cancer
Code List
Ovarian cancer or a primary peritonitis carcinomatosa
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Sister/daughter has breast cancer prior to the age of 36
integer
Breast cancer
Code List
Sister/daughter has breast cancer prior to the age of 36
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Sisiter/ daughter has unilateral breast canster prior to the age of 51
integer
Breast cancer
Code List
Sisiter/ daughter has unilateral breast canster prior to the age of 51
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Sister/ daughter has bilateral breast canster prior to the age of 51
integer
Breast cancer
Code List
Sister/ daughter has bilateral breast canster prior to the age of 51
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Sister/ daughter has unilateral or blateral breast canster after the age of 50
integer
Breast cancer
Code List
Sister/ daughter has unilateral or blateral breast canster after the age of 50
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Brother/ son has breast cancer
integer
Breast cancer
Code List
Brother/ son has breast cancer
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Sister/ daughter has ovarian cancer or a primary peritonitis carcinomatosa
integer
Breast cancer
Code List
Sister/ daughter has ovarian cancer or a primary peritonitis carcinomatosa
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Total
Item
Total
integer
Item Group
B. Matrilineality
Item
Relatuve has breast cancer prior to the age of 36
integer
Breast cancer
Code List
Relatuve has breast cancer prior to the age of 36
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Relative has unilateral breast canster prior to the age of 51
integer
Breast cancer
Code List
Relative has unilateral breast canster prior to the age of 51
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Relative has bilateral breast canster prior to the age of 51
integer
Breast cancer
Code List
Relative has bilateral breast canster prior to the age of 51
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Relative has unilateral or blateral breast canster after the age of 50
integer
Breast cancer
Code List
Relative has unilateral or blateral breast canster after the age of 50
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Male relative has breast cancer
integer
Breast cancer
Code List
Male relative has breast cancer
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Relative has ovarian cancer or a primary peritonitis carcinomatosa
integer
Breast cancer
Code List
Relative has ovarian cancer or a primary peritonitis carcinomatosa
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Total
Item
Total
integer
Item Group
Patrilineality
Item
Relative has breast cancer prior to the age of 36
integer
Breast cancer
Code List
Relative has breast cancer prior to the age of 36
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Relative has unilateral breast canster prior to the age of 51
integer
Breast cancer
Code List
Relative has unilateral breast canster prior to the age of 51
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Relative has bilateral breast canster prior to the age of 51
integer
Breast cancer
Code List
Relative has bilateral breast canster prior to the age of 51
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Relative has unilateral or blateral breast canster after the age of 50
integer
Breast cancer
Code List
Relative has unilateral or blateral breast canster after the age of 50
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Male relative has breast cancer
integer
Breast cancer
Code List
Male relative has breast cancer
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Item
Relative has ovarian cancer or a primary peritonitis carcinomatosa
integer
Breast cancer
Code List
Relative has ovarian cancer or a primary peritonitis carcinomatosa
CL Item
Amount (1)
CL Item
Weighting  (2)
CL Item
Result (3)
Total
Item
Total
integer
Item Group
D. Higher score B. matrilineality or C. patrilineality
Item Group
E. Total A+D
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