ID

1314

Description

E5204 FACT/GOG-Neurotoxicity Combination Chemotherapy With or Without Bevacizumab in Treating Patients Who Have Had Surgery for Stage II or Stage III Rectal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=08FF61C8-655A-6373-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=08FF61C8-655A-6373-E044-0003BA3F9857

Keywords

Versions (2)
  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

August 27, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Colorectal Cancer NCT00303628 Quality of Life - E5204 FACT/GOG-Ntx - 2440880v1.0

English

(version 4)

1 forms  
  1. StudyEvent: E5204 FACT/GOG-Ntx
    1. (version 4)
Unnamed1
Description

Unnamed1

DCI Name
Description

CollectedDataFormName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus Property
C19464
UMLS 2011AA Property
C0376315
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus ObjectClass
C25452
Registration Step
Description

RegistrationStepNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25646
UMLS 2011AA ObjectClass
C1514821
NCI Thesaurus Property
C16154
UMLS 2011AA Property
C1704379
NCI Thesaurus ValueDomain
C16154
UMLS 2011AA ValueDomain
C1704379
Reporting Period
Description

ReportingEvaluationPeriodType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25214
UMLS 2011AA ObjectClass
C0220825
NCI Thesaurus Property
C25616
UMLS 2011AA Property
C1948053
NCI Thesaurus ObjectClass
C25651
UMLS 2011AA ObjectClass
C0700287
Patient Initials (PLACE ID LABEL HERE Last, First)
Description

PatientInitialsName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
ECOG Protocol Number
Description

ProtocolECOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25491
UMLS 2011AA Property
C1512162
ECOG Protocol Number
Description

ProtocolECOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25491
UMLS 2011AA Property
C1512162
ECOG Patient ID
Description

PatientECOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25491
UMLS 2011AA Property
C1512162
ECOG Patient ID
Description

PatientECOGIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25491
UMLS 2011AA Property
C1512162
Participating Group Protocol No.
Description

ProtocolParticipatingIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participating Group Patient ID
Description

PatientParticipatingIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Institution/Affiliate
Description

CombinedInstitutionName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25454
UMLS 2011AA ObjectClass
C0205195
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
Assessment Date
Description

PatientAssessmentDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
Unnamed2
Description

Unnamed2

I have numbness or tingling in my hands
Description

NeurotoxicityPatientParaesthesiaHandAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C27961
UMLS 2011AA ObjectClass
C0235032
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0239836
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I have numbness or tingling in my feet
Description

NeurotoxicityPatientParaesthesiaFootAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C27961
UMLS 2011AA ObjectClass
C0235032
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
CL108114
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I feel discomfort in my hands
Description

NeurotoxicityPatientHandDiscomfortAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C27961
UMLS 2011AA ObjectClass
C0235032
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C32712
UMLS 2011AA Property
C0018563
NCI Metathesaurus Property
CL047845
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I feel discomfort in my feet
Description

NeurotoxicityPatientFootDiscomfortAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C27961
UMLS 2011AA ObjectClass
C0235032
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
CL050515
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I have joint pain or muscle cramps
Description

NeurotoxicityPatientArthralgiaAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C27961
UMLS 2011AA ObjectClass
C0235032
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0003862
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I feel weak all over
Description

NeurotoxicityPatientMuscleWeaknessAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C27961
UMLS 2011AA ObjectClass
C0235032
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0151786
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I have trouble hearing
Description

NeurotoxicityPatientHearingAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C27961
UMLS 2011AA ObjectClass
C0235032
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C16670
UMLS 2011AA Property
C0018767
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I get a ringing or buzzing in my ears
Description

NeurotoxicityPatientTinnitusAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C27961
UMLS 2011AA ObjectClass
C0235032
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C50772
UMLS 2011AA Property
C0040264
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I have trouble buttoning buttons
Description

NeurotoxicityPatientHandCoordinationAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C27961
UMLS 2011AA ObjectClass
C0235032
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C25462
UMLS 2011AA Property
C0700114
NCI Thesaurus Property
C32712
UMLS 2011AA Property
C0018563
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I have trouble feeling the shape of small objects when they are in my hand
Description

NeurotoxicityPatientHypoaesthesiaAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C27961
UMLS 2011AA ObjectClass
C0235032
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0020580
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I have trouble walking
Description

NeurotoxicityPatientParaparesisAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C27961
UMLS 2011AA ObjectClass
C0235032
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0221166
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I have pain in my hands or feet when I am exposed to cold temperatures
Description

NeurotoxicityPatientTemperatureSenseAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C27961
UMLS 2011AA ObjectClass
C0235032
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0039478
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I have difficulty breathing when I am exposed to cold temperatures
Description

NeurotoxicityPatientColdDyspneaAssessmentQualityofLifeScale

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C27961
UMLS 2011AA ObjectClass
C0235032
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C2998
UMLS 2011AA Property
C0013404
NCI Metathesaurus Property
CL330269
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
Investigator Signature
Description

Investigator Signature

Investigator Signature
Description

InvestigatorSignatureText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Investigator Signature Date
Description

InvestigatorSignatureDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
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Similar models

(version 4)

1 forms
  1. StudyEvent: E5204 FACT/GOG-Ntx
    1. (version 4)
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
CollectedDataFormName
Item
DCI Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25452 (NCI Thesaurus ObjectClass)
RegistrationStepNumber
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25646 (NCI Thesaurus ObjectClass)
C1514821 (UMLS 2011AA ObjectClass)
C16154 (NCI Thesaurus Property)
C1704379 (UMLS 2011AA Property)
C16154 (NCI Thesaurus ValueDomain)
C1704379 (UMLS 2011AA ValueDomain)
Item
Reporting Period
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25214 (NCI Thesaurus ObjectClass)
C0220825 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus ObjectClass)
C0700287 (UMLS 2011AA ObjectClass)
CL.1
Code List
Reporting Period
CL Item
Baseline (Baseline)
C25213 (NCI Thesaurus)
C1442488 (UMLS 2011AA)
CL Item
Cycle 4, Day 1 (Cycle 4, Day 1)
CL Item
3 Months Post-chemotherapy (3 months post-chemotherapy)
CL Item
12 Months Post-chemotherapy (12 months post-chemotherapy)
PatientInitialsName
Item
Patient Initials (PLACE ID LABEL HERE Last, First)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
ProtocolECOGIdentifierNumber
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
ProtocolECOGIdentifierNumber
Item
ECOG Protocol Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
PatientECOGIdentifierNumber
Item
ECOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
PatientECOGIdentifierNumber
Item
ECOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
ProtocolParticipatingIdentifierNumber
Item
Participating Group Protocol No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientParticipatingIdentifierNumber
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CombinedInstitutionName
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
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)
PatientAssessmentDate
Item
Assessment Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
Item Group
Unnamed2
Item
I have numbness or tingling in my hands
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass)
C0235032 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0239836 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.2
Code List
I have numbness or tingling in my hands
CL Item
A Little Bit (A little bit)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I have numbness or tingling in my feet
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass)
C0235032 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL108114 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.3
Code List
I have numbness or tingling in my feet
CL Item
A Little Bit (A little bit)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I feel discomfort in my hands
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass)
C0235032 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C32712 (NCI Thesaurus Property)
C0018563 (UMLS 2011AA Property)
CL047845 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.4
Code List
I feel discomfort in my hands
CL Item
A Little Bit (A little bit)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I feel discomfort in my feet
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass)
C0235032 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
CL050515 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.5
Code List
I feel discomfort in my feet
CL Item
A Little Bit (A little bit)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I have joint pain or muscle cramps
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass)
C0235032 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0003862 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.6
Code List
I have joint pain or muscle cramps
CL Item
A Little Bit (A little bit)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I feel weak all over
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass)
C0235032 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0151786 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.7
Code List
I feel weak all over
CL Item
A Little Bit (A little bit)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I have trouble hearing
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass)
C0235032 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C16670 (NCI Thesaurus Property)
C0018767 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.8
Code List
I have trouble hearing
CL Item
A Little Bit (A little bit)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I get a ringing or buzzing in my ears
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass)
C0235032 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C50772 (NCI Thesaurus Property)
C0040264 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.9
Code List
I get a ringing or buzzing in my ears
CL Item
A Little Bit (A little bit)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I have trouble buttoning buttons
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass)
C0235032 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C32712 (NCI Thesaurus Property)
C0018563 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.10
Code List
I have trouble buttoning buttons
CL Item
A Little Bit (A little bit)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I have trouble feeling the shape of small objects when they are in my hand
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass)
C0235032 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0020580 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.11
Code List
I have trouble feeling the shape of small objects when they are in my hand
CL Item
A Little Bit (A little bit)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I have trouble walking
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass)
C0235032 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0221166 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.12
Code List
I have trouble walking
CL Item
A Little Bit (A little bit)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I have pain in my hands or feet when I am exposed to cold temperatures
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass)
C0235032 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0039478 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.13
Code List
I have pain in my hands or feet when I am exposed to cold temperatures
CL Item
A Little Bit (A little bit)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I have difficulty breathing when I am exposed to cold temperatures
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C27961 (NCI Thesaurus ObjectClass)
C0235032 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C2998 (NCI Thesaurus Property)
C0013404 (UMLS 2011AA Property)
CL330269 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.14
Code List
I have difficulty breathing when I am exposed to cold temperatures
CL Item
A Little Bit (A little bit)
CL Item
Not At All (Not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
C70543 (NCI Thesaurus)
C2003901 (UMLS 2011AA)
CL Item
Quite A Bit (Quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Somewhat (Somewhat)
C91215 (NCI Thesaurus)
CL Item
Very Much (Very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item Group
Investigator Signature
InvestigatorSignatureText
Item
Investigator Signature
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Investigator Signature Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
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