ID

1340

Descripción

E5204 FACT-D Subscale 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=08EBCA50-68B9-62C3-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=08EBCA50-68B9-62C3-E044-0003BA3F9857

Palabras clave

Versiones (3)
  1. 27/8/12 27/8/12 -
  2. 9/1/15 9/1/15 - Martin Dugas
  3. 16/6/15 16/6/15 -
Subido en

27 de agosto de 2012

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy
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Colorectal Cancer NCT00303628 Quality of Life - E5204 FACT-D Subscale - 2440312v1.0

Inglés

(version 4)

1 formularios  
  1. StudyEvent: E5204 FACT-D Subscale
    1. (version 4)
Unnamed1
Descripción

Unnamed1

DCI Name
Descripción

CollectedDataFormName

Tipo de datos

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
Descripción

RegistrationStepNumber

Tipo de datos

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
Descripción

ReportingEvaluationPeriodType

Tipo de datos

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
Descripción

PatientInitialsName

Tipo de datos

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
Descripción

ProtocolECOGIdentifierNumber

Tipo de datos

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
Descripción

ProtocolECOGIdentifierNumber

Tipo de datos

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
Descripción

PatientECOGIdentifierNumber

Tipo de datos

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
Descripción

PatientECOGIdentifierNumber

Tipo de datos

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.
Descripción

ProtocolParticipatingIdentifierNumber

Tipo de datos

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
Descripción

PatientParticipatingIdentifierNumber

Tipo de datos

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
Descripción

CombinedInstitutionName

Tipo de datos

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
Unnamed2
Descripción

Unnamed2

Assessment Date
Descripción

PatientAssessmentDate

Tipo de datos

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
I have control of my bowels
Descripción

BowelPatientIncontinenceAssessmentQualityofLifeScale

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C12736
UMLS 2011AA ObjectClass
C0021853
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0021167
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I move my bowels more frequently than usual
Descripción

BowelPatientFrequencyAssessmentQualityofLifeScale

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C12736
UMLS 2011AA ObjectClass
C0021853
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C25515
UMLS 2011AA Property
C0439603
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I am afraid to be far from a toliet
Descripción

BowelPatientAnxietyAssessmentQualityofLifeScale

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C12736
UMLS 2011AA ObjectClass
C0021853
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C26696
UMLS 2011AA Property
C0003467
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I have to limit my social activity because of diarrhea
Descripción

BowelPatientSocialDistanceAssessmentQualityofLifeScale

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C12736
UMLS 2011AA ObjectClass
C0021853
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0037412
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I have to limit my physical activity because of diarrhea
Descripción

BowelPatientRoutineActivityAssessmentQualityofLifeScale

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C12736
UMLS 2011AA ObjectClass
C0021853
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C43431
UMLS 2011AA Property
C0441655
NCI Thesaurus Property
C47893
UMLS 2011AA Property
C0205547
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I have to limit my sexual activity because of diarrhea
Descripción

BowelPatientSexBehaviorAssessmentQualityofLifeScale

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C12736
UMLS 2011AA ObjectClass
C0021853
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C17127
UMLS 2011AA Property
C0036864
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I am embarrassed by having diarrhea
Descripción

BowelPatientEmbarrassmentAssessmentQualityofLifeScale

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C12736
UMLS 2011AA ObjectClass
C0021853
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0679112
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I have abdominal cramps or discomfort due to my diarrhea
Descripción

BowelPatientAbdominalCrampAssessmentQualityofLifeScale

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C12736
UMLS 2011AA ObjectClass
C0021853
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C34331
UMLS 2011AA Property
C0000729
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
My problem with diarrhea keeps/wakes me up at night
Descripción

BowelPatientInsomniaAssessmentQualityofLifeScale

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C12736
UMLS 2011AA ObjectClass
C0021853
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C28286
UMLS 2011AA Property
C0917801
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I must move my bowels frequently to avoid accidents
Descripción

BowelPatientDefecationUrgencyAssessmentQualityofLifeScale

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C12736
UMLS 2011AA ObjectClass
C0021853
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0426636
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
I wear protection for soiling of stool
Descripción

BowelPatientUndergarmentAssessmentQualityofLifeScale

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C12736
UMLS 2011AA ObjectClass
C0021853
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Metathesaurus Property
C0453880
NCI Thesaurus ValueDomain
C25664
UMLS 2011AA ValueDomain
C0349674
NCI Thesaurus ValueDomain
C17047
UMLS 2011AA ValueDomain
C0518214
Investigator Signature
Descripción

Investigator Signature

Investigator Signature
Descripción

InvestigatorSignatureText

Tipo de datos

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
Descripción

InvestigatorSignatureDate

Tipo de datos

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 formularios
  1. StudyEvent: E5204 FACT-D Subscale
    1. (version 4)
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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
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)
Item Group
Unnamed2
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
I have control of my bowels
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12736 (NCI Thesaurus ObjectClass)
C0021853 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0021167 (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 control of my bowels
CL Item
Not At All (not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (a little bit)
CL Item
Somewhat (somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Very Much (very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I move my bowels more frequently than usual
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12736 (NCI Thesaurus ObjectClass)
C0021853 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25515 (NCI Thesaurus Property)
C0439603 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.3
Code List
I move my bowels more frequently than usual
CL Item
Not At All (not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (a little bit)
CL Item
Somewhat (somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Very Much (very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I am afraid to be far from a toliet
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12736 (NCI Thesaurus ObjectClass)
C0021853 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C26696 (NCI Thesaurus Property)
C0003467 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.4
Code List
I am afraid to be far from a toliet
CL Item
Not At All (not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (a little bit)
CL Item
Somewhat (somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Very Much (very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I have to limit my social activity because of diarrhea
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12736 (NCI Thesaurus ObjectClass)
C0021853 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0037412 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.5
Code List
I have to limit my social activity because of diarrhea
CL Item
Not At All (not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (a little bit)
CL Item
Somewhat (somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Very Much (very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I have to limit my physical activity because of diarrhea
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12736 (NCI Thesaurus ObjectClass)
C0021853 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C43431 (NCI Thesaurus Property)
C0441655 (UMLS 2011AA Property)
C47893 (NCI Thesaurus Property)
C0205547 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.6
Code List
I have to limit my physical activity because of diarrhea
CL Item
Not At All (not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (a little bit)
CL Item
Somewhat (somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Very Much (very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I have to limit my sexual activity because of diarrhea
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12736 (NCI Thesaurus ObjectClass)
C0021853 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C17127 (NCI Thesaurus Property)
C0036864 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.7
Code List
I have to limit my sexual activity because of diarrhea
CL Item
Not At All (not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (a little bit)
CL Item
Somewhat (somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Very Much (very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I am embarrassed by having diarrhea
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12736 (NCI Thesaurus ObjectClass)
C0021853 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0679112 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.8
Code List
I am embarrassed by having diarrhea
CL Item
Not At All (not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (a little bit)
CL Item
Somewhat (somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Very Much (very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I have abdominal cramps or discomfort due to my diarrhea
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12736 (NCI Thesaurus ObjectClass)
C0021853 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C34331 (NCI Thesaurus Property)
C0000729 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.9
Code List
I have abdominal cramps or discomfort due to my diarrhea
CL Item
Not At All (not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (a little bit)
CL Item
Somewhat (somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Very Much (very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
My problem with diarrhea keeps/wakes me up at night
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12736 (NCI Thesaurus ObjectClass)
C0021853 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C28286 (NCI Thesaurus Property)
C0917801 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.10
Code List
My problem with diarrhea keeps/wakes me up at night
CL Item
Not At All (not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (a little bit)
CL Item
Somewhat (somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Very Much (very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I must move my bowels frequently to avoid accidents
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12736 (NCI Thesaurus ObjectClass)
C0021853 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0426636 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.11
Code List
I must move my bowels frequently to avoid accidents
CL Item
Not At All (not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (a little bit)
CL Item
Somewhat (somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (quite a bit)
C91216 (NCI Thesaurus)
C91216 (NCI Thesaurus)
CL Item
Very Much (very much)
C91217 (NCI Thesaurus)
C91217 (NCI Thesaurus)
Item
I wear protection for soiling of stool
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C12736 (NCI Thesaurus ObjectClass)
C0021853 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C0453880 (NCI Metathesaurus Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ValueDomain)
C0518214 (UMLS 2011AA ValueDomain)
CL.12
Code List
I wear protection for soiling of stool
CL Item
Not At All (not at all)
C91213 (NCI Thesaurus)
C91213 (NCI Thesaurus)
CL Item
A Little Bit (a little bit)
CL Item
Somewhat (somewhat)
C91215 (NCI Thesaurus)
CL Item
Quite A Bit (quite a bit)
C91216 (NCI Thesaurus)
C91216 (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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