ID

1535

Beskrivning

Z6051 International Index of Erectile Function Questionnaire (IIEF) Laparoscopic-Assisted Resection or Open Resection in Treating Patients With Stage IIA, Stage IIIA, or Stage IIIB Rectal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4AE9A885-FEFA-574B-E044-0003BA3F9857

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4AE9A885-FEFA-574B-E044-0003BA3F9857

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27 augusti 2012

DOI

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Creative Commons BY-NC 3.0 Legacy

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Colorectal Cancer NCT00726622 Quality of Life - Z6051 International Index of Erectile Function Questionnaire (IIEF) - 2740994v1.0

model
Detaljer

INSTRUCTIONS: These questions ask about your sexual feelings and responses during the past 4 weeks. Please answer the following questions as honestly and clearly as possible. Your responses will be kept completely confidential.

1 Formulär

StudyEvent: Z6051 International Index of Erectile Function Questionnaire (IIEF)
1. INSTRUCTIONS: These questions ask about your sexual feelings and responses during the past 4 weeks. Please answer the following questions as honestly and clearly as possible. Your responses will be kept completely confidential.

Name

Typ

Description | Question | Decode (Coded Value)

Datatyp

Alias

Header Module

Item Group

Header Module

AmericanCollegeofSurgeonsOncologyGroupVisitPeriodAmericanCollegeofSurgeonsOncologyGroupVisitPeriodType

Item

Visit

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C19712 (NCI Thesaurus ObjectClass)
C1515944 (UMLS 2011AA ObjectClass)
C25716 (NCI Thesaurus ObjectClass)
C0545082 (UMLS 2011AA ObjectClass)

CL.1

Code List

Visit

CL Item

Pre-operative (Pre-Op)

CL Item

4-6 Weeks Post-surgery (4-6 weeks post-surgery)

CL Item

Month 3 (Month 3)

CL Item

Month 12 (Month 12)

PatientCoordinatingIdentifierNumber

Item

Patient ID (Pt. ID issued during registration unless pt. previously registered to an ACOSOG study.)

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

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)

InstitutionName

Item

Institution Name

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

InstitutionIdentifierNumber

Item

Institution No.

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

AssessmentPerformedDate

Item

Date

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ObjectClass)
C25367 (NCI Thesaurus ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)

Unnamed 1

Item Group

Unnamed 1

SexBehaviorQualityofLifeErectionOccurrenceAssessmentScale

Item

Over the past 4 weeks, how often were you able to have an erection during sexual activity

text

C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass)
C0036864 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25740 (NCI Thesaurus Property)
C0030847 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)

CL.2

Code List

Over the past 4 weeks, how often were you able to have an erection during sexual activity

CL Item

A Few Times (A few times)

CL Item

Almost Always/ Always (almost always/ always)

CL Item

Almost Never/ Never (almost never/ never)

CL Item

Most Times (Most times)

CL Item

No Sexual Activity (No sexual activity)

CL Item

Sometimes (Sometimes)

SexBehaviorQualityofLifeErectionSufficientPenetrationOccurrenceAssessmentScale

Item

Over the past 4 weeks, when you had erections with sexual stimulation, how often were your erections hard enough for penetration

text

C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass)
C0036864 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25740 (NCI Thesaurus Property)
C0030847 (UMLS 2011AA Property)
C25612 (NCI Thesaurus Property)
C0205321 (UMLS 2011AA Property)
C63351 (NCI Thesaurus Property)
C0205410 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)

CL.3

Code List

Over the past 4 weeks, when you had erections with sexual stimulation, how often were your erections hard enough for penetration

CL Item

A Few Times (A few times)

CL Item

Almost Always/ Always (almost always/ always)

CL Item

Almost Never/ Never (almost never/ never)

CL Item

Most Times (Most times)

CL Item

No Sexual Activity (No sexual activity)

CL Item

Sometimes (Sometimes)

SexBehaviorQualityofLifePenetrationOccurrenceAssessmentScale

Item

Over the past 4 weeks, when you attempted sexual intercourse, how often were you able to penetrate (enter) your partner

text

C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass)
C0036864 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25612 (NCI Thesaurus Property)
C0205321 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)

CL.4

Code List

Over the past 4 weeks, when you attempted sexual intercourse, how often were you able to penetrate (enter) your partner

CL Item

A Few Times (A few times)

CL Item

Almost Always/ Always (almost always/ always)

CL Item

Almost Never/ Never (almost never/ never)

CL Item

Most Times (Most times)

CL Item

No Sexual Activity (No sexual activity)

CL Item

Sometimes (Sometimes)

SexBehaviorQualityofLifeErectionPostPenetrationOccurrenceAssessmentScale

Item

Over the past 4 weeks, during sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner

text

C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass)
C0036864 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25740 (NCI Thesaurus Property)
C0030847 (UMLS 2011AA Property)
C25612 (NCI Thesaurus Property)
C0205321 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)

CL.5

Code List

Over the past 4 weeks, during sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner

CL Item

A Few Times (A few times)

CL Item

Almost Always/ Always (almost always/ always)

CL Item

Almost Never/ Never (almost never/ never)

CL Item

Did Not Attempt Intercourse (Did not attempt intercourse)

CL Item

Most Times (Most times)

CL Item

Sometimes (Sometimes)

SexBehaviorQualityofLifeErectionMaintenanceDifficultyAssessmentScale

Item

Over the past 4 weeks, during sexual intercourse, how difficult was it to maintain your erection to complete intercourse

text

C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass)
C0036864 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C53297 (NCI Thesaurus Property)
C0024501 (UMLS 2011AA Property)
C62189 (NCI Thesaurus Property)
C1299586 (UMLS 2011AA Property)
C25740 (NCI Thesaurus Property)
C0030847 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)

CL.6

Code List

Over the past 4 weeks, during sexual intercourse, how difficult was it to maintain your erection to complete intercourse

CL Item

Did Not Attempt Intercourse (Did not attempt intercourse)

CL Item

Difficult (Difficult)

CL Item

Not Difficult (Not difficult)

CL Item

Slightly Difficult (Slightly difficult)

CL Item

Very Difficult (Very difficult)

CL Item

Extremely Difficult (Extremely difficult)

SexBehaviorQualityofLifeSexualIntercourseOccurrenceAssessmentScale

Item

Over the past 4 weeks, how many times did you attempt sexual intercourse

text

C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass)
C0036864 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C72881 (NCI Thesaurus Property)
C0009253 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)

CL.7

Code List

Over the past 4 weeks, how many times did you attempt sexual intercourse

CL Item

Five To Six Attempts (Five to six attempts)

CL Item

More Than Eleven Attempts (More than eleven attempts)

CL Item

No Attempt (No attempt)

CL Item

One To Two Attempts (One to two attempts)

CL Item

Seven To Ten Attempts (Seven to ten attempts)

CL Item

Three To Four Attempts (Three to four attempts)

SexBehaviorQualityofLifeSexualIntercourseSatisfactionOccurrenceAssessmentScale

Item

Over the past 4 weeks, when you attempted sexual intercourse, how often was it satisfactory for you

text

C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass)
C0036864 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C62185 (NCI Thesaurus Property)
C0242428 (UMLS 2011AA Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C72881 (NCI Thesaurus Property)
C0009253 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)

CL.8

Code List

Over the past 4 weeks, when you attempted sexual intercourse, how often was it satisfactory for you

CL Item

A Few Times (A few times)

CL Item

Almost Always/ Always (almost always/ always)

CL Item

Almost Never/ Never (almost never/ never)

CL Item

Did Not Attempt Intercourse (Did not attempt intercourse)

CL Item

Most Times (Most times)

CL Item

Sometimes (Sometimes)

SexBehaviorQualityofLifeSexualIntercourseSatisfactionAssessmentScale

Item

Over the past 4 weeks, how much did you enjoy sexual intercourse

text

C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass)
C0036864 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C62185 (NCI Thesaurus Property)
C0242428 (UMLS 2011AA Property)
C72881 (NCI Thesaurus Property)
C0009253 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)

CL.9

Code List

Over the past 4 weeks, how much did you enjoy sexual intercourse

CL Item

Fairly Enjoyable (Fairly enjoyable)

CL Item

Highly Enjoyable (Highly enjoyable)

CL Item

No Enjoyment (No enjoyment)

CL Item

No Intercourse (No intercourse)

CL Item

Not Very Enjoyable (Not very enjoyable)

CL Item

Very Highly Enjoyable (Very highly enjoyable)

SexBehaviorQualityofLifeSexualIntercourseEjaculationOccurrenceAssessmentScale

Item

Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you ejaculate

text

C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass)
C0036864 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C72881 (NCI Thesaurus Property)
C0009253 (UMLS 2011AA Property)
C16531 (NCI Thesaurus Property)
C0013746 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)

CL.10

Code List

Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you ejaculate

CL Item

A Few Times (A few times)

CL Item

Almost Always/ Always (almost always/ always)

CL Item

Almost Never/ Never (almost never/ never)

CL Item

Did Not Attempt Intercourse (Did not attempt intercourse)

CL Item

Most Times (Most times)

CL Item

Sometimes (Sometimes)

SexBehaviorQualityofLifeOrgasmOccurrenceAssessmentScale

Item

Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax

text

C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass)
C0036864 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C73521 (NCI Thesaurus Property)
C0029260 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)

CL.11

Code List

Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax

CL Item

A Few Times (A few times)

CL Item

Almost Always/ Always (almost always/ always)

CL Item

Almost Never/ Never (almost never/ never)

CL Item

Most Times (Most times)

CL Item

Sometimes (Sometimes)

SexBehaviorQualityofLifeLibidoAssessmentScale

Item

Over the past 4 weeks, how often did you feel sexual desire

text

CL.12

Code List

Over the past 4 weeks, how often did you feel sexual desire

CL Item

A Few Times (A few times)

CL Item

Almost Always/ Always (almost always/ always)

CL Item

Almost Never/ Never (almost never/ never)

CL Item

Most Times (Most times)

CL Item

Sometimes (Sometimes)

SexBehaviorQualityofLifeLibidoOccurrenceAssessmentScale

Item

Over the past 4 weeks, how would you rate your level of sexual desire

text

C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass)
C0036864 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C37986 (NCI Thesaurus Property)
C0023618 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)

CL.13

Code List

Over the past 4 weeks, how would you rate your level of sexual desire

CL Item

High (High)

C25227 (NCI Thesaurus)
C0205250 (UMLS 2011AA)

CL Item

Low (Low)

C54722 (NCI Thesaurus)
C0205251 (UMLS 2011AA)

CL Item

Moderation (Moderate)

C61376 (NCI Thesaurus)
C1881878 (UMLS 2011AA)

CL Item

Very High (Very high)

CL Item

Very Low Or None At All (Very low or none at all)

SexBehaviorQualityofLifeOverallSatisfactionAssessmentScale

Item

Over the past 4 weeks, how satisfied have you been with your overall sexual life

text

C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass)
C0036864 (UMLS 2011AA ObjectClass)
C25605 (NCI Thesaurus Property)
C1561607 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property)
C62185 (NCI Thesaurus Property)
C0242428 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)

CL.14

Code List

Over the past 4 weeks, how satisfied have you been with your overall sexual life

CL Item

About Equally Satisfied And Dissatisfied (About equally satisfied and dissatisfied)

CL Item

Moderately Dissatisfied (Moderately dissatisfied)

CL Item

Moderately Satisfied (Moderately satisfied)

CL Item

Very Dissatisfied (Very dissatisfied)

CL Item

Very Satisfied (Very satisfied)

SexBehaviorQualityofLifeSatisfactionAssessmentScale

Item

Over the past 4 weeks, how satisfied have you been with your sexual relationship with your partner

text

CL.15

Code List

Over the past 4 weeks, how satisfied have you been with your sexual relationship with your partner

CL Item

About Equally Satisfied And Dissatisfied (About equally satisfied and dissatisfied)

CL Item

Moderately Dissatisfied (Moderately dissatisfied)

CL Item

Moderately Satisfied (Moderately satisfied)

CL Item

Very Dissatisfied (Very dissatisfied)

CL Item

Very Satisfied (Very satisfied)

SexBehaviorQualityofLifeErectionConfidenceAssessmentScale

Item

Over the past 4 weeks, how do you rate your confidence that you could have and keep an erection

text

C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C17127 (NCI Thesaurus ObjectClass)
C0036864 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C43367 (NCI Thesaurus Property)
C1704726 (UMLS 2011AA Property)
C25740 (NCI Thesaurus Property)
C0030847 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)

CL.16

Code List

Over the past 4 weeks, how do you rate your confidence that you could have and keep an erection

CL Item

Very Low (Very low)

CL Item

High (High)

C25227 (NCI Thesaurus)
C0205250 (UMLS 2011AA)

CL Item

Low (Low)

C54722 (NCI Thesaurus)
C0205251 (UMLS 2011AA)

CL Item

Moderation (Moderate)

C61376 (NCI Thesaurus)
C1881878 (UMLS 2011AA)

CL Item

Very High (Very high)

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Colorectal Cancer NCT00726622 Quality of Life - Z6051 International Index of Erectile Function Questionnaire (IIEF) - 2740994v1.0

INSTRUCTIONS: These questions ask about your sexual feelings and responses during the past 4 weeks. Please answer the following questions as honestly and clearly as possible. Your responses will be kept completely confidential.

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INSTRUCTIONS: These questions ask about your sexual feelings and responses during the past 4 weeks. Please answer the following questions as honestly and clearly as possible. Your responses will be kept completely confidential.