ID

13565

Beskrivning

Phase 1 clinical trial for intrasurgical hyperthermic intraperitoneal chemoperfusion with cisplatin (HIPEC) in patients with ovarian cancer recidiv EudraCT Nr.: 2010-024352-28 Principal investigator und authorized representative of Sponsor: PD Dr. med. Oliver Zivanovic Center for Obstetrics and Gynaecology University Hospital Bonn Sigmund-Freud-Str. 25 53105 Bonn Sponsor: Rheinische Friedrich-Wilhelms-Universität Bonn represented by the Dean of Medical Faculty

Nyckelord

  1. 2016-02-16 2016-02-16 -
Uppladdad den

16 februari 2016

DOI

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Licens

Creative Commons BY-NC 3.0

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Visit 8 Phase 1 clinical trial for intrasurgical hyperthermic intraperitoneal chemoperfusion with cisplatin (HIPEC) in patients with ovarian cancer recidiv

Case Report Form (HIPEC) Visit 8

Visit 8: Day 21 post-OP
Beskrivning

Visit 8: Day 21 post-OP

Patient ID
Beskrivning

Patient ID

Datatyp

integer

Alias
UMLS CUI [1]
C1269815
CRF number
Beskrivning

CRF number

Datatyp

integer

Alias
UMLS CUI [1,1]
C1516308
UMLS CUI [1,2]
C0449788
Date of visit
Beskrivning

Date

Datatyp

date

Alias
UMLS CUI [1]
C0011008
Vital signs and physical examination
Beskrivning

Vital signs and physical examination

Heart rate count
Beskrivning

Heart rate

Datatyp

integer

Måttenheter
  • bpm
Alias
UMLS CUI [1]
C0018810
bpm
Blood pressure measurement
Beskrivning

Blood pressure

Datatyp

text

Måttenheter
  • mm/Hg
Alias
UMLS CUI [1]
C0005823
mm/Hg
Body Temperature
Beskrivning

Body Temperature

Datatyp

float

Måttenheter
  • °C
Alias
UMLS CUI [1]
C0005903
°C
Performance status (ECOG):
Beskrivning

ECOG

Datatyp

text

Alias
UMLS CUI [1]
C1520224
General physical condition
Beskrivning

General physical condition

Datatyp

text

Alias
UMLS CUI [1]
C1142435
General physical condition:further comment
Beskrivning

General physical condition

Datatyp

text

Alias
UMLS CUI [1]
C1142435
Skin assessment
Beskrivning

Skin assessment

Datatyp

text

Alias
UMLS CUI [1]
C0419929
Skin assessment:further comment
Beskrivning

Skin assessment

Datatyp

text

Alias
UMLS CUI [1]
C0419929
Cardiovascular system assessment
Beskrivning

Cardiovascular system

Datatyp

text

Alias
UMLS CUI [1]
C0007226
Cardiovascular system:further comment
Beskrivning

Cardiovascular system

Datatyp

text

Alias
UMLS CUI [1]
C0007226
Respiratory system assessment
Beskrivning

Respiratory system

Datatyp

text

Alias
UMLS CUI [1]
C0035237
Respiratory System:further comment
Beskrivning

Respiratory system

Datatyp

text

Alias
UMLS CUI [1]
C0035237
Otorhinolaryngologic diseases
Beskrivning

Otorhinolaryngologic diseases

Datatyp

text

Alias
UMLS CUI [1]
C0029896
Otorhinolaryngologic diseases:further comment
Beskrivning

Otorhinolaryngologic diseases

Datatyp

text

Alias
UMLS CUI [1]
C0029896
Abdominal examination
Beskrivning

Abdominal examination

Datatyp

text

Alias
UMLS CUI [1]
C0438120
Abdominal examination:further comment
Beskrivning

Abdominal examination

Datatyp

text

Alias
UMLS CUI [1]
C0438120
Lymphatic system
Beskrivning

Lymphatic system

Datatyp

text

Alias
UMLS CUI [1]
C0024235
Lymphatic system:further comment
Beskrivning

Lymphatic system

Datatyp

text

Alias
UMLS CUI [1]
C0024235
Mucous Membranes
Beskrivning

Mucous Membranes

Datatyp

text

Alias
UMLS CUI [1]
C0026724
Mucous Membranes:further comment
Beskrivning

Mucous Membranes

Datatyp

text

Alias
UMLS CUI [1]
C0026724
Neurological examination
Beskrivning

Neurological examination

Datatyp

text

Alias
UMLS CUI [1]
C0027853
Neurological examination:further comment
Beskrivning

Neurological examination

Datatyp

text

Alias
UMLS CUI [1]
C0027853
Gynecological Examination
Beskrivning

Gynecological Examination

Datatyp

text

Alias
UMLS CUI [1]
C0200044
Gynecological Examination:further comment
Beskrivning

Gynecological Examination

Datatyp

text

Alias
UMLS CUI [1]
C0200044
Urinary Tract and Kidney Examination
Beskrivning

Urinary Tract and Kidney

Datatyp

text

Alias
UMLS CUI [1,1]
C0042027
UMLS CUI [1,2]
C0227665
Urinary Tract and Kidneys:further comment
Beskrivning

Urinary Tract and Kidneys

Datatyp

text

Alias
UMLS CUI [1,1]
C0042027
UMLS CUI [1,2]
C0227665
Please specify any other clinically significant findings
Beskrivning

Other Findings

Datatyp

text

Alias
UMLS CUI [1]
C0159135
Has concomitant medication been subject to change? If "Yes", please fill in concomitant medication form.
Beskrivning

Concomitant agent

Datatyp

boolean

Alias
UMLS CUI [1]
C2347852
Recording of CTCAE: Have any AE occurred since the last Visit? If `Yes` please fill in AE-Form
Beskrivning

CTCAE

Datatyp

boolean

Alias
UMLS CUI [1]
C1516728
Laboratory results
Beskrivning

Laboratory results

Date of venous blood sampling
Beskrivning

First venipuncture of that day

Datatyp

date

Alias
UMLS CUI [1,1]
C0190979
UMLS CUI [1,2]
C0011008
Time of laboratory procedure (according to laboratory sheet)
Beskrivning

Time of laboratory procedure

Datatyp

time

Alias
UMLS CUI [1]
C0022885
Creatinine measurement value
Beskrivning

Serologic tests Creatinine

Datatyp

integer

Måttenheter
  • mg/dl
Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0201975
mg/dl
Is Creatinine value within normal range?
Beskrivning

Serologic tests Creatinine

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0201975
Are Creatinine measurement findings clinically significant? If `Yes`, please fill in AE- form.
Beskrivning

Serologic tests Creatinine

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0201975
Urea measurement value
Beskrivning

Serologic tests Urea measurement

Datatyp

integer

Måttenheter
  • mg/dl
Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0523961
mg/dl
Is Urea measurement value within normal range?
Beskrivning

Serologic tests Urea measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0523961
Are Urea measurement findings clinically significant? If `Yes`, please fill in AE-Form.
Beskrivning

Serologic tests Urea measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0523961
Bilirubin measurement value
Beskrivning

Serologic tests Bilirubin measurement

Datatyp

integer

Måttenheter
  • mg/dl
Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0344395
mg/dl
Is Bilirubin measurement value within normal range?
Beskrivning

Serologic tests Bilirubin measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0344395
Are Bilirubin measurement findings clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Serologic tests Bilirubin measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0344395
GPT measurement value
Beskrivning

Serologic tests GPT measurement

Datatyp

integer

Måttenheter
  • U/l
Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0201836
U/l
Is GPT value within normal range?
Beskrivning

Serologic tests GPT measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0201836
Are GPT measurement findings clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Serologic measurement GPT measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0201836
GOT measurement value
Beskrivning

Serologic tests GOT measurement

Datatyp

integer

Måttenheter
  • U/l
Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0201899
U/l
Is GOT value within normal range?
Beskrivning

Serologic tests GOT measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0201899
Are GOT measurement findings clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Serologic tests GOT measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0201899
GGT measurement value
Beskrivning

Serologic tests GGT measurement

Datatyp

integer

Måttenheter
  • U/l
Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0202035
U/l
Is GGT measurement within normal range?
Beskrivning

Serologic tests GGT Measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0202035
Are GGT measurement findings clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Serologic tests GGT measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0202035
Albumin measurement value
Beskrivning

Serologic tests Albumin measurement

Datatyp

integer

Måttenheter
  • g/l
Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0201838
g/l
Is Albumin measurement within normal range?
Beskrivning

Serologic tests Albumin measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0201838
Are Albumin measurement findings clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Serologic tests Albumin measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0201838
Serum potassium measurement value
Beskrivning

Serologic tests serum potassium

Datatyp

integer

Måttenheter
  • mmol/l
Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0302353
mmol/l
Is serum potassium measurement value within normal range?
Beskrivning

Serologic tests serum potassium

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0302353
Are serum potassium measurement findings clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Serologic tests serum potassium

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0302353
Serum sodium measurement value
Beskrivning

Serologic tests serum sodium

Datatyp

integer

Måttenheter
  • mmol/l
Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0523891
mmol/l
Is serum sodium measurement value within normal range?
Beskrivning

Serologic tests serum sodium

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0523891
Are serum sodium measurement findings clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Serologic tests serum sodium

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0523891
Serum calcium measurement value
Beskrivning

Serologic tests serum calcium

Datatyp

integer

Måttenheter
  • mmol/l
Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0728876
mmol/l
Is serum calcium measurement value within normal range?
Beskrivning

Serologic tests serum calcium

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0728876
Are serum calcium measurement findings clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Serologic measurement serum calcium

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C0728876
Serum chloride measurement value
Beskrivning

Serologic tests serum chloride

Datatyp

integer

Måttenheter
  • mmol/l
Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C1317978
mmol/l
Is serum chloride measurement value within normal range?
Beskrivning

Serologic tests serum chloride

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C1317978
Are serum chloride measurement findings clinically significant? If `Yes` , please fill in AE form.
Beskrivning

Serologic tests serum chloride

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0036743
UMLS CUI [1,2]
C1317978
Hemoglobin measurement value
Beskrivning

Blood cell count: hemoglobin measurement

Datatyp

integer

Måttenheter
  • g/dl
Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0518015
g/dl
Is the hemoglobin measurement value within normal range?
Beskrivning

Blood cell count: hemoglobin measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0518015
Are hemoglobin measurement findings clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Blood cell count: hemoglobin measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0518015
Hematocrit level
Beskrivning

Blood cell count hematocrit level

Datatyp

integer

Måttenheter
  • %
Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0518014
%
Is the hematocrit level within normal range?
Beskrivning

Blood cell count: Hematocrit level

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0518014
Are findings in hematocrit level clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Blood cell count: Hematocrit level

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0518014
Erythrocyte measurement value
Beskrivning

Blood cell count: erythrocyte measurement

Datatyp

integer

Måttenheter
  • mg/dl
Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0014792
mg/dl
Is the erythrocyte measurement value within normal range?
Beskrivning

Blood cell count: erythrocyte measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0014792
Are findings in erythrocyte measurement clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Blood cell count: erythrocyte measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0014792
Leukocyte measurement value
Beskrivning

Blood cell count: leukocyte measurement

Datatyp

integer

Måttenheter
  • U/l
Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0023516
U/l
Is the leukocyte measurement value within normal range?
Beskrivning

Blood cell count: leukocyte measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0023516
Are findings in Leukocyte measurement clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Blood cell count:Leukocyte measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0023516
Absolute neutrophils count measurement value
Beskrivning

Blood cell count: Neutrophils count

Datatyp

integer

Måttenheter
  • U/l
Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0948762
U/l
Is the count of neutrophils within normal range?
Beskrivning

Blood cell count:neutrophils count

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0948762
Are findings in neutrophils count clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Blood cell count:neutrophils count

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0948762
Lymphocyte count measurement value
Beskrivning

Blood cell count:lymphocyte count

Datatyp

integer

Måttenheter
  • U/l
Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0200635
U/l
Is the count of lymphocytes within normal range?
Beskrivning

Blood cell count:lymphocyte count

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0200635
Are findings in lymphocyte count clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Blood cell count:lymphocyte count

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0200635
Monocyte measurement value
Beskrivning

Blood cell count: Monocyte count

Datatyp

integer

Måttenheter
  • g/l
Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0750880
g/l
Is the monocyte measurement value within normal range?
Beskrivning

Blood cell count: Monocyte count

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0750880
Are findings in monocyte count clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Blood cell count: Monocyte count

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0750880
Eosinophils measurement value
Beskrivning

Blood cell count: Eosinophils count

Datatyp

integer

Måttenheter
  • g/l
Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0200638
g/l
Is the count of eosinophils within normal range?
Beskrivning

Blood cell count: Eosinophils count

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0200638
Are findings in eosinophils count clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Blood cell count: eosinophils count

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0200638
Basophil measurement value
Beskrivning

Blood cell count: Basophil count

Datatyp

integer

Måttenheter
  • g/l
Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0200641
g/l
Is the count of basophils within normal range?
Beskrivning

Blood cell count: Basophil count

Datatyp

boolean

Are findings in basophil count clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Blood cell count: Basophil count

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0200641
Platelets count measurement value
Beskrivning

Blood cell count: platelets count

Datatyp

integer

Måttenheter
  • g/l
Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0032181
g/l
Is the platelets count within normal range?
Beskrivning

Blood cell count: platelets count

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0032181
Are findings in platelets count clinically significant? If `Yes`, please fill in AE form.
Beskrivning

Blood cell count: platelets count

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0005771
UMLS CUI [1,2]
C0032181
Tumor marker CA125 measurement value
Beskrivning

Tumor marker measurement

Datatyp

integer

Alias
UMLS CUI [1,1]
C0474700
UMLS CUI [1,2]
C0973166
Is measurement value of tumor marker CA 125 within normal range?
Beskrivning

Tumor marker measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0474700
UMLS CUI [1,2]
C0973166
Are findings in tumor marker CA 125 clinically significant?
Beskrivning

Tumor marker measurement

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0474700
UMLS CUI [1,2]
C0973166
Urine sample date and time
Beskrivning

Urine Sample Date

Datatyp

datetime

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0200354
Urine Sample test results
Beskrivning

Urine Sample

Datatyp

text

Alias
UMLS CUI [1,1]
C0200354
UMLS CUI [1,2]
C0456984
If urine sample test results are abnormal, please specify
Beskrivning

Urine sample test results

Datatyp

text

Alias
UMLS CUI [1,1]
C0200354
UMLS CUI [1,2]
C0456984
Inquiry of dose limiting toxicity
Beskrivning

Inquiry of dose limiting toxicity

Has a dose limiting toxicity been reached?
Beskrivning

Answer only after consultation with data and safety monitoring board (DSMB).

Datatyp

boolean

Alias
UMLS CUI [1,1]
C1512043
UMLS CUI [1,2]
C0013221
If dose limiting toxicity has been reached, please specify the date it occurred
Beskrivning

Date of dose limiting toxicity

Datatyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C1512043
UMLS CUI [1,3]
C0013221
Please specify the toxicities that have occurred and give the corresponding AE number
Beskrivning

Dose limiting toxicity

Datatyp

text

Alias
UMLS CUI [1,1]
C1512043
UMLS CUI [1,2]
C0013221
Has maximum tolerated dose been reached?
Beskrivning

Answer only after consultation with data and safety monitoring board (DSMB).

Datatyp

boolean

Alias
UMLS CUI [1]
C0752079
Confirmation of correctness
Beskrivning

Confirmation of correctness

Name of Investigator
Beskrivning

Name of Investigator

Datatyp

text

Alias
UMLS CUI [1]
C0008961
Signature by investigator: I personally controlled all entries into this form for this patient. All data and statements in this CRF are complete and correct
Beskrivning

Signature

Datatyp

text

Alias
UMLS CUI [1]
C1519316
Date of completion of this form
Beskrivning

Date

Datatyp

date

Alias
UMLS CUI [1]
C0011008

Similar models

Case Report Form (HIPEC) Visit 8

Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Visit 8: Day 21 post-OP
Patient ID
Item
Patient ID
integer
C1269815 (UMLS CUI [1])
CRF number
Item
CRF number
integer
C1516308 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
Date
Item
Date of visit
date
C0011008 (UMLS CUI [1])
Item Group
Vital signs and physical examination
Heart rate
Item
Heart rate count
integer
C0018810 (UMLS CUI [1])
Blood pressure
Item
Blood pressure measurement
text
C0005823 (UMLS CUI [1])
Body Temperature
Item
Body Temperature
float
C0005903 (UMLS CUI [1])
Item
Performance status (ECOG):
text
C1520224 (UMLS CUI [1])
Code List
Performance status (ECOG):
CL Item
0 (0)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
Item
General physical condition
text
C1142435 (UMLS CUI [1])
Code List
General physical condition
CL Item
normal (1)
CL Item
pathological (2)
CL Item
not assessed (3)
General physical condition
Item
General physical condition:further comment
text
C1142435 (UMLS CUI [1])
Item
Skin assessment
text
C0419929 (UMLS CUI [1])
Code List
Skin assessment
CL Item
normal (1)
CL Item
pathological (2)
CL Item
not assessed (3)
Skin assessment
Item
Skin assessment:further comment
text
C0419929 (UMLS CUI [1])
Item
Cardiovascular system assessment
text
C0007226 (UMLS CUI [1])
Code List
Cardiovascular system assessment
CL Item
normal (1)
CL Item
pathological (2)
CL Item
not assessed (3)
Cardiovascular system
Item
Cardiovascular system:further comment
text
C0007226 (UMLS CUI [1])
Item
Respiratory system assessment
text
C0035237 (UMLS CUI [1])
Code List
Respiratory system assessment
CL Item
normal (1)
CL Item
pathological (2)
CL Item
not assessed (3)
Respiratory system
Item
Respiratory System:further comment
text
C0035237 (UMLS CUI [1])
Item
Otorhinolaryngologic diseases
text
C0029896 (UMLS CUI [1])
Code List
Otorhinolaryngologic diseases
CL Item
none (1)
CL Item
yes (2)
CL Item
not assessed (3)
Otorhinolaryngologic diseases
Item
Otorhinolaryngologic diseases:further comment
text
C0029896 (UMLS CUI [1])
Item
Abdominal examination
text
C0438120 (UMLS CUI [1])
Code List
Abdominal examination
CL Item
normal (1)
CL Item
pathological (2)
CL Item
not assessed (3)
Abdominal examination
Item
Abdominal examination:further comment
text
C0438120 (UMLS CUI [1])
Item
Lymphatic system
text
C0024235 (UMLS CUI [1])
Code List
Lymphatic system
CL Item
normal (1)
CL Item
pathological (2)
CL Item
not assessed (3)
Lymphatic system
Item
Lymphatic system:further comment
text
C0024235 (UMLS CUI [1])
Item
Mucous Membranes
text
C0026724 (UMLS CUI [1])
Code List
Mucous Membranes
CL Item
normal (1)
CL Item
pathological (2)
CL Item
not assessed (3)
Mucous Membranes
Item
Mucous Membranes:further comment
text
C0026724 (UMLS CUI [1])
Item
Neurological examination
text
C0027853 (UMLS CUI [1])
Code List
Neurological examination
CL Item
Normal (1)
CL Item
Pathological (2)
CL Item
not assessed (3)
Neurological examination
Item
Neurological examination:further comment
text
C0027853 (UMLS CUI [1])
Item
Gynecological Examination
text
C0200044 (UMLS CUI [1])
Code List
Gynecological Examination
CL Item
normal (1)
CL Item
pathological (2)
CL Item
not assessed (3)
Gynecological Examination
Item
Gynecological Examination:further comment
text
C0200044 (UMLS CUI [1])
Item
Urinary Tract and Kidney Examination
text
C0042027 (UMLS CUI [1,1])
C0227665 (UMLS CUI [1,2])
Code List
Urinary Tract and Kidney Examination
CL Item
normal (1)
CL Item
pathological (2)
CL Item
not assessed (3)
Urinary Tract and Kidneys
Item
Urinary Tract and Kidneys:further comment
text
C0042027 (UMLS CUI [1,1])
C0227665 (UMLS CUI [1,2])
Other Findings
Item
Please specify any other clinically significant findings
text
C0159135 (UMLS CUI [1])
Concomitant agent
Item
Has concomitant medication been subject to change? If "Yes", please fill in concomitant medication form.
boolean
C2347852 (UMLS CUI [1])
CTCAE
Item
Recording of CTCAE: Have any AE occurred since the last Visit? If `Yes` please fill in AE-Form
boolean
C1516728 (UMLS CUI [1])
Item Group
Laboratory results
Date of venous blood sampling
Item
Date of venous blood sampling
date
C0190979 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Time of laboratory procedure
Item
Time of laboratory procedure (according to laboratory sheet)
time
C0022885 (UMLS CUI [1])
Serologic tests Creatinine
Item
Creatinine measurement value
integer
C0036743 (UMLS CUI [1,1])
C0201975 (UMLS CUI [1,2])
Serologic tests Creatinine
Item
Is Creatinine value within normal range?
boolean
C0036743 (UMLS CUI [1,1])
C0201975 (UMLS CUI [1,2])
Serologic tests Creatinine
Item
Are Creatinine measurement findings clinically significant? If `Yes`, please fill in AE- form.
boolean
C0036743 (UMLS CUI [1,1])
C0201975 (UMLS CUI [1,2])
Serologic tests Urea measurement
Item
Urea measurement value
integer
C0036743 (UMLS CUI [1,1])
C0523961 (UMLS CUI [1,2])
Serologic tests Urea measurement
Item
Is Urea measurement value within normal range?
boolean
C0036743 (UMLS CUI [1,1])
C0523961 (UMLS CUI [1,2])
Serologic tests Urea measurement
Item
Are Urea measurement findings clinically significant? If `Yes`, please fill in AE-Form.
boolean
C0036743 (UMLS CUI [1,1])
C0523961 (UMLS CUI [1,2])
Serologic tests Bilirubin measurement
Item
Bilirubin measurement value
integer
C0036743 (UMLS CUI [1,1])
C0344395 (UMLS CUI [1,2])
Serologic tests Bilirubin measurement
Item
Is Bilirubin measurement value within normal range?
boolean
C0036743 (UMLS CUI [1,1])
C0344395 (UMLS CUI [1,2])
Serologic tests Bilirubin measurement
Item
Are Bilirubin measurement findings clinically significant? If `Yes`, please fill in AE form.
boolean
C0036743 (UMLS CUI [1,1])
C0344395 (UMLS CUI [1,2])
Serologic tests GPT measurement
Item
GPT measurement value
integer
C0036743 (UMLS CUI [1,1])
C0201836 (UMLS CUI [1,2])
Serologic tests GPT measurement
Item
Is GPT value within normal range?
boolean
C0036743 (UMLS CUI [1,1])
C0201836 (UMLS CUI [1,2])
Serologic measurement GPT measurement
Item
Are GPT measurement findings clinically significant? If `Yes`, please fill in AE form.
boolean
C0036743 (UMLS CUI [1,1])
C0201836 (UMLS CUI [1,2])
Serologic tests GOT measurement
Item
GOT measurement value
integer
C0036743 (UMLS CUI [1,1])
C0201899 (UMLS CUI [1,2])
Serologic tests GOT measurement
Item
Is GOT value within normal range?
boolean
C0036743 (UMLS CUI [1,1])
C0201899 (UMLS CUI [1,2])
Serologic tests GOT measurement
Item
Are GOT measurement findings clinically significant? If `Yes`, please fill in AE form.
boolean
C0036743 (UMLS CUI [1,1])
C0201899 (UMLS CUI [1,2])
Serologic tests GGT measurement
Item
GGT measurement value
integer
C0036743 (UMLS CUI [1,1])
C0202035 (UMLS CUI [1,2])
Serologic tests GGT Measurement
Item
Is GGT measurement within normal range?
boolean
C0036743 (UMLS CUI [1,1])
C0202035 (UMLS CUI [1,2])
Serologic tests GGT measurement
Item
Are GGT measurement findings clinically significant? If `Yes`, please fill in AE form.
boolean
C0036743 (UMLS CUI [1,1])
C0202035 (UMLS CUI [1,2])
Serologic tests Albumin measurement
Item
Albumin measurement value
integer
C0036743 (UMLS CUI [1,1])
C0201838 (UMLS CUI [1,2])
Serologic tests Albumin measurement
Item
Is Albumin measurement within normal range?
boolean
C0036743 (UMLS CUI [1,1])
C0201838 (UMLS CUI [1,2])
Serologic tests Albumin measurement
Item
Are Albumin measurement findings clinically significant? If `Yes`, please fill in AE form.
boolean
C0036743 (UMLS CUI [1,1])
C0201838 (UMLS CUI [1,2])
Serologic tests serum potassium
Item
Serum potassium measurement value
integer
C0036743 (UMLS CUI [1,1])
C0302353 (UMLS CUI [1,2])
Serologic tests serum potassium
Item
Is serum potassium measurement value within normal range?
boolean
C0036743 (UMLS CUI [1,1])
C0302353 (UMLS CUI [1,2])
Serologic tests serum potassium
Item
Are serum potassium measurement findings clinically significant? If `Yes`, please fill in AE form.
boolean
C0036743 (UMLS CUI [1,1])
C0302353 (UMLS CUI [1,2])
Serologic tests serum sodium
Item
Serum sodium measurement value
integer
C0036743 (UMLS CUI [1,1])
C0523891 (UMLS CUI [1,2])
Serologic tests serum sodium
Item
Is serum sodium measurement value within normal range?
boolean
C0036743 (UMLS CUI [1,1])
C0523891 (UMLS CUI [1,2])
Serologic tests serum sodium
Item
Are serum sodium measurement findings clinically significant? If `Yes`, please fill in AE form.
boolean
C0036743 (UMLS CUI [1,1])
C0523891 (UMLS CUI [1,2])
Serologic tests serum calcium
Item
Serum calcium measurement value
integer
C0036743 (UMLS CUI [1,1])
C0728876 (UMLS CUI [1,2])
Serologic tests serum calcium
Item
Is serum calcium measurement value within normal range?
boolean
C0036743 (UMLS CUI [1,1])
C0728876 (UMLS CUI [1,2])
Serologic measurement serum calcium
Item
Are serum calcium measurement findings clinically significant? If `Yes`, please fill in AE form.
boolean
C0036743 (UMLS CUI [1,1])
C0728876 (UMLS CUI [1,2])
Serologic tests serum chloride
Item
Serum chloride measurement value
integer
C0036743 (UMLS CUI [1,1])
C1317978 (UMLS CUI [1,2])
Serologic tests serum chloride
Item
Is serum chloride measurement value within normal range?
boolean
C0036743 (UMLS CUI [1,1])
C1317978 (UMLS CUI [1,2])
Serologic tests serum chloride
Item
Are serum chloride measurement findings clinically significant? If `Yes` , please fill in AE form.
boolean
C0036743 (UMLS CUI [1,1])
C1317978 (UMLS CUI [1,2])
Blood cell count: hemoglobin measurement
Item
Hemoglobin measurement value
integer
C0005771 (UMLS CUI [1,1])
C0518015 (UMLS CUI [1,2])
Blood cell count: hemoglobin measurement
Item
Is the hemoglobin measurement value within normal range?
boolean
C0005771 (UMLS CUI [1,1])
C0518015 (UMLS CUI [1,2])
Blood cell count: hemoglobin measurement
Item
Are hemoglobin measurement findings clinically significant? If `Yes`, please fill in AE form.
boolean
C0005771 (UMLS CUI [1,1])
C0518015 (UMLS CUI [1,2])
Blood cell count hematocrit level
Item
Hematocrit level
integer
C0005771 (UMLS CUI [1,1])
C0518014 (UMLS CUI [1,2])
Blood cell count: Hematocrit level
Item
Is the hematocrit level within normal range?
boolean
C0005771 (UMLS CUI [1,1])
C0518014 (UMLS CUI [1,2])
Blood cell count: Hematocrit level
Item
Are findings in hematocrit level clinically significant? If `Yes`, please fill in AE form.
boolean
C0005771 (UMLS CUI [1,1])
C0518014 (UMLS CUI [1,2])
Blood cell count: erythrocyte measurement
Item
Erythrocyte measurement value
integer
C0005771 (UMLS CUI [1,1])
C0014792 (UMLS CUI [1,2])
Blood cell count: erythrocyte measurement
Item
Is the erythrocyte measurement value within normal range?
boolean
C0005771 (UMLS CUI [1,1])
C0014792 (UMLS CUI [1,2])
Blood cell count: erythrocyte measurement
Item
Are findings in erythrocyte measurement clinically significant? If `Yes`, please fill in AE form.
boolean
C0005771 (UMLS CUI [1,1])
C0014792 (UMLS CUI [1,2])
Blood cell count: leukocyte measurement
Item
Leukocyte measurement value
integer
C0005771 (UMLS CUI [1,1])
C0023516 (UMLS CUI [1,2])
Blood cell count: leukocyte measurement
Item
Is the leukocyte measurement value within normal range?
boolean
C0005771 (UMLS CUI [1,1])
C0023516 (UMLS CUI [1,2])
Blood cell count:Leukocyte measurement
Item
Are findings in Leukocyte measurement clinically significant? If `Yes`, please fill in AE form.
boolean
C0005771 (UMLS CUI [1,1])
C0023516 (UMLS CUI [1,2])
Blood cell count: Neutrophils count
Item
Absolute neutrophils count measurement value
integer
C0005771 (UMLS CUI [1,1])
C0948762 (UMLS CUI [1,2])
Blood cell count:neutrophils count
Item
Is the count of neutrophils within normal range?
boolean
C0005771 (UMLS CUI [1,1])
C0948762 (UMLS CUI [1,2])
Blood cell count:neutrophils count
Item
Are findings in neutrophils count clinically significant? If `Yes`, please fill in AE form.
boolean
C0005771 (UMLS CUI [1,1])
C0948762 (UMLS CUI [1,2])
Blood cell count:lymphocyte count
Item
Lymphocyte count measurement value
integer
C0005771 (UMLS CUI [1,1])
C0200635 (UMLS CUI [1,2])
Blood cell count:lymphocyte count
Item
Is the count of lymphocytes within normal range?
boolean
C0005771 (UMLS CUI [1,1])
C0200635 (UMLS CUI [1,2])
Blood cell count:lymphocyte count
Item
Are findings in lymphocyte count clinically significant? If `Yes`, please fill in AE form.
boolean
C0005771 (UMLS CUI [1,1])
C0200635 (UMLS CUI [1,2])
Blood cell count: Monocyte count
Item
Monocyte measurement value
integer
C0005771 (UMLS CUI [1,1])
C0750880 (UMLS CUI [1,2])
Blood cell count: Monocyte count
Item
Is the monocyte measurement value within normal range?
boolean
C0005771 (UMLS CUI [1,1])
C0750880 (UMLS CUI [1,2])
Blood cell count: Monocyte count
Item
Are findings in monocyte count clinically significant? If `Yes`, please fill in AE form.
boolean
C0005771 (UMLS CUI [1,1])
C0750880 (UMLS CUI [1,2])
Blood cell count: Eosinophils count
Item
Eosinophils measurement value
integer
C0005771 (UMLS CUI [1,1])
C0200638 (UMLS CUI [1,2])
Blood cell count: Eosinophils count
Item
Is the count of eosinophils within normal range?
boolean
C0005771 (UMLS CUI [1,1])
C0200638 (UMLS CUI [1,2])
Blood cell count: eosinophils count
Item
Are findings in eosinophils count clinically significant? If `Yes`, please fill in AE form.
boolean
C0005771 (UMLS CUI [1,1])
C0200638 (UMLS CUI [1,2])
Blood cell count: Basophil count
Item
Basophil measurement value
integer
C0005771 (UMLS CUI [1,1])
C0200641 (UMLS CUI [1,2])
Blood cell count: Basophil count
Item
Is the count of basophils within normal range?
boolean
Blood cell count: Basophil count
Item
Are findings in basophil count clinically significant? If `Yes`, please fill in AE form.
boolean
C0005771 (UMLS CUI [1,1])
C0200641 (UMLS CUI [1,2])
Blood cell count: platelets count
Item
Platelets count measurement value
integer
C0005771 (UMLS CUI [1,1])
C0032181 (UMLS CUI [1,2])
Blood cell count: platelets count
Item
Is the platelets count within normal range?
boolean
C0005771 (UMLS CUI [1,1])
C0032181 (UMLS CUI [1,2])
Blood cell count: platelets count
Item
Are findings in platelets count clinically significant? If `Yes`, please fill in AE form.
boolean
C0005771 (UMLS CUI [1,1])
C0032181 (UMLS CUI [1,2])
Tumor marker measurement
Item
Tumor marker CA125 measurement value
integer
C0474700 (UMLS CUI [1,1])
C0973166 (UMLS CUI [1,2])
Tumor marker measurement
Item
Is measurement value of tumor marker CA 125 within normal range?
boolean
C0474700 (UMLS CUI [1,1])
C0973166 (UMLS CUI [1,2])
Tumor marker measurement
Item
Are findings in tumor marker CA 125 clinically significant?
boolean
C0474700 (UMLS CUI [1,1])
C0973166 (UMLS CUI [1,2])
Urine Sample Date
Item
Urine sample date and time
datetime
C0011008 (UMLS CUI [1,1])
C0200354 (UMLS CUI [1,2])
Item
Urine Sample test results
text
C0200354 (UMLS CUI [1,1])
C0456984 (UMLS CUI [1,2])
Code List
Urine Sample test results
CL Item
normal (1)
CL Item
abnormal, clinically not significant (2)
CL Item
abnormal, clinically significant (3)
Urine sample test results
Item
If urine sample test results are abnormal, please specify
text
C0200354 (UMLS CUI [1,1])
C0456984 (UMLS CUI [1,2])
Item Group
Inquiry of dose limiting toxicity
Dose limiting toxicity
Item
Has a dose limiting toxicity been reached?
boolean
C1512043 (UMLS CUI [1,1])
C0013221 (UMLS CUI [1,2])
Date of dose limiting toxicity
Item
If dose limiting toxicity has been reached, please specify the date it occurred
date
C0011008 (UMLS CUI [1,1])
C1512043 (UMLS CUI [1,2])
C0013221 (UMLS CUI [1,3])
Dose limiting toxicity
Item
Please specify the toxicities that have occurred and give the corresponding AE number
text
C1512043 (UMLS CUI [1,1])
C0013221 (UMLS CUI [1,2])
Maximum tolerated dose
Item
Has maximum tolerated dose been reached?
boolean
C0752079 (UMLS CUI [1])
Item Group
Confirmation of correctness
Name of Investigator
Item
Name of Investigator
text
C0008961 (UMLS CUI [1])
Signature
Item
Signature by investigator: I personally controlled all entries into this form for this patient. All data and statements in this CRF are complete and correct
text
C1519316 (UMLS CUI [1])
Date
Item
Date of completion of this form
date
C0011008 (UMLS CUI [1])

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