ID

1798

Beskrivning

RTOG-00522 HP: Radiation Therapy Oncology Group Miscellaneous Patient Assessment Form Radiation Therapy and Cisplatin With or Without Cetuximab in Treating Patients With Stage III or Stage IV Head and Neck Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F5E8260F-4AEB-157F-E034-0003BA3F9857

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F5E8260F-4AEB-157F-E034-0003BA3F9857

Nyckelord

Versioner (6)
  1. 2012-09-19 2012-09-19 -
  2. 2014-08-11 2014-08-11 - Martin Dugas
  3. 2014-08-11 2014-08-11 - Martin Dugas
  4. 2015-01-09 2015-01-09 - Martin Dugas
  5. 2015-06-21 2015-06-21 -
  6. 2021-09-20 2021-09-20 -
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19 september 2012

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy
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Head and Neck Cancer NCT00265941 Quality of Life - RTOG-0522 HP: Radiation Therapy Oncology Group Miscellaneous Patient Assessment Form - 2222582v1.0

Engelsk

No Instruction available.

1 Formulär  
  1. StudyEvent: RTOG-0522 HP: Radiation Therapy Oncology Group Miscellaneous Patient Assessment Form
    1. No Instruction available.
Unnamed Module 1
Beskrivning

Unnamed Module 1

RTOG Study No.
Beskrivning

ProtocolRTOGIdentifierNumber

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C19778
UMLS 2011AA Property
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Case #
Beskrivning

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C19778
UMLS 2011AA ObjectClass
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C49152
UMLS 2011AA Property
C1706256
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Institution Name
Beskrivning

InstitutionName

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Institution No.
Beskrivning

InstitutionIdentifierNumber

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Initials
Beskrivning

PatientInitialsName

Datatyp

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
RTOG Patient ID
Beskrivning

PatientRadiationTherapyOncologyGroupIdentifierNumber

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C19778
UMLS 2011AA Property
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Amended data
Beskrivning

DataAmendedInd-3

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unamed Module 2
Beskrivning

Unamed Module 2

MOBILITY
Beskrivning

QOLMobilityAssessmentStatus

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Metathesaurus Property
C0449580
SELF CARE
Beskrivning

QualityofLifeSelfCareAssessmentStatus

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
NCI Thesaurus Property
C15324
UMLS 2011AA Property
C0518889
USUAL ACTIVITIES (e.g. work, study, housework, family, or leisure activities)
Beskrivning

QOLPhyscialActivityAssessmentStatus

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C17708
UMLS 2011AA Property
C0026606
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
PAIN/DISCOMFORT
Beskrivning

QOLPainAssessmentStatus

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C3303
UMLS 2011AA Property
C0030193
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
ANXIETY/DEPRESSION
Beskrivning

QOLAnxietyAssessmentStatus

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus Property
C26696
UMLS 2011AA Property
C0003467
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Unnamed Module 3
Beskrivning

Unnamed Module 3

Score (Best Imaginable Health State)
Beskrivning

PatientHealthScore

Datatyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25178
UMLS 2011AA Property
C0018684
NCI Thesaurus ValueDomain
C25338
UMLS 2011AA ValueDomain
C0449820
HAVE YOU EXPERIENCED SERIOUS ILLNESS In yourself?
Beskrivning

PatientSeriousSicknessInd-2

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C54035
UMLS 2011AA Property
C0205404
NCI Metathesaurus Property
C0221423
HAVE YOU EXPERIENCED SERIOUS ILLNESS In your family?
Beskrivning

ImmediateSeriousSicknessInd-2

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C54035
UMLS 2011AA Property
C0205404
NCI Metathesaurus ObjectClass
CL282488
NCI Metathesaurus Property
C0221423
HAVE YOU EXPERIENCED SERIOUS ILLNESS In caring for others?
Beskrivning

CareAssistantPatientSeriousSicknessInd-2

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus ObjectClass
CL259930
NCI Thesaurus Property
C54035
UMLS 2011AA Property
C0205404
NCI Metathesaurus Property
C0221423
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
WHAT IS YOUR AGE IN YEARS?
Beskrivning

PatientAgeYearCount

Datatyp

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ValueDomain
C29848
UMLS 2011AA ValueDomain
C0439234
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus Property
C25150
UMLS 2011AA Property
C0001779
Are you
Beskrivning

QualityofLifePatientGenderAssessmentCategory

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C17357
UMLS 2011AA ObjectClass
C0079399
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
ARE YOU A current smoker
Beskrivning

SmokingCurrentUseInd-3

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25471
UMLS 2011AA Property
C0521116
NCI Thesaurus ObjectClass
C17934
UMLS 2011AA ObjectClass
C0453996
NCI Metathesaurus Property
C0449865
ARE YOU An ex-smoker
Beskrivning

SmokingUseInd-3

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C17934
UMLS 2011AA ObjectClass
C0453996
NCI Thesaurus Property
C25340
UMLS 2011AA Property
C0457083
ARE YOU A never smoker
Beskrivning

NoSmokingHistoryInd-2

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C49487
UMLS 2011AA ObjectClass
C1298908
NCI Thesaurus ObjectClass
C17934
UMLS 2011AA ObjectClass
C0453996
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
DO YOU NOW, OR DID YOU EVER, WORK IN HEALTH OR SOCIAL SERVICES?
Beskrivning

SocialWorkHistoryInd-2

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus ObjectClass
C17142
UMLS 2011AA ObjectClass
C0037441
IF SO, IN WHAT CAPACITY?
Beskrivning

SocialWorkHistoryRoleSpecify

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus ObjectClass
C17142
UMLS 2011AA ObjectClass
C0037441
NCI Thesaurus ValueDomain
C25199
UMLS 2011AA ValueDomain
C0035820
WHICH OF THE FOLLOWING BEST DESCRIBES YOUR MAIN ACTIVITY?
Beskrivning

PersonOccupationType

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25193
UMLS 2011AA Property
C0028811
Other
Beskrivning

PersonOccupationSpecify

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25193
UMLS 2011AA Property
C0028811
DID YOUR EDUCATION CONTINUE AFTER THE MINIMUM SCHOOL LEAVING AGE?
Beskrivning

ContinuedEducationMinimumAgeatLeavingSchoolInd-2

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16529
UMLS 2011AA ObjectClass
C0013622
NCI Metathesaurus ObjectClass
C0750536
NCI Thesaurus Property
C25570
UMLS 2011AA Property
C1524031
NCI Metathesaurus Property
CL238333
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
DO YOU HAVE A DEGREE OR EQUIVALENT PROFESSIONAL QUALIFICATION?
Beskrivning

PatientEducationalStatusInd-2

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus Property
C0013658
IF YOU KNOW YOUR POSTCODE, WOULD YOU PLEASE WRITE IT HERE
Beskrivning

QualityofLifePatientAddressPostalCode

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Metathesaurus ObjectClass
C1442065
NCI Thesaurus Property
C25621
UMLS 2011AA Property
C1514254
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Tillbaka till toppen

Similar models

No Instruction available.

1 Formulär
  1. StudyEvent: RTOG-0522 HP: Radiation Therapy Oncology Group Miscellaneous Patient Assessment Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Unnamed Module 1
ProtocolRTOGIdentifierNumber
Item
RTOG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
Item
Case #
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus ObjectClass)
C1514695 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C49152 (NCI Thesaurus Property)
C1706256 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
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)
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)
PatientRadiationTherapyOncologyGroupIdentifierNumber
Item
RTOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item
Amended data
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Amended data
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unamed Module 2
Item
MOBILITY
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C0449580 (NCI Metathesaurus Property)
CL.2
Code List
MOBILITY
CL Item
I Have No Problems In Walking About (I have no problems in walking about)
CL Item
I Have Some Problems In Walking About (I have some problems in walking about)
CL Item
I Am Confined To Bed (I am confined to bed)
Item
SELF CARE
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C15324 (NCI Thesaurus Property)
C0518889 (UMLS 2011AA Property)
CL.3
Code List
SELF CARE
CL Item
I Have No Problems With Self Care (I have no problems with self care)
CL Item
I Have Some Problems Washing Or Dressing Myself (I have some problems washing or dressing myself)
CL Item
I Am Unable To Wash Or Dress Myself (I am unable to wash or dress myself)
Item
USUAL ACTIVITIES (e.g. work, study, housework, family, or leisure activities)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C17708 (NCI Thesaurus Property)
C0026606 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.4
Code List
USUAL ACTIVITIES (e.g. work, study, housework, family, or leisure activities)
CL Item
I Have No Problems With Performing My Usual Activities (I have no problems with performing my usual activities)
CL Item
I Have Some Problems With Performing My Usual Activities (I have some problems with performing my usual activities)
CL Item
I Am Unable To Perform My Usual Activities (I am unable to perform my usual activities)
Item
PAIN/DISCOMFORT
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C3303 (NCI Thesaurus Property)
C0030193 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.5
Code List
PAIN/DISCOMFORT
CL Item
I Have No Pain Or Discomfort (I have no pain or discomfort)
CL Item
I Have Moderate Pain Or Discomfort (I have moderate pain or discomfort)
CL Item
I Have Extreme Pain Or Discomfort (I have extreme pain or discomfort)
Item
ANXIETY/DEPRESSION
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C26696 (NCI Thesaurus Property)
C0003467 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.6
Code List
ANXIETY/DEPRESSION
CL Item
I Am Not Anxious Or Depressed (I am not anxious or depressed)
CL Item
I Am Moderately Anxious Or Depressed (I am moderately anxious or depressed)
CL Item
I Am Extremely Anxious Or Depressed (I am extremely anxious or depressed)
Item Group
Unnamed Module 3
PatientHealthScore
Item
Score (Best Imaginable Health State)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25178 (NCI Thesaurus Property)
C0018684 (UMLS 2011AA Property)
C25338 (NCI Thesaurus ValueDomain)
C0449820 (UMLS 2011AA ValueDomain)
Item
HAVE YOU EXPERIENCED SERIOUS ILLNESS In yourself?
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C54035 (NCI Thesaurus Property)
C0205404 (UMLS 2011AA Property)
C0221423 (NCI Metathesaurus Property)
CL.7
Code List
HAVE YOU EXPERIENCED SERIOUS ILLNESS In yourself?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
HAVE YOU EXPERIENCED SERIOUS ILLNESS In your family?
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C54035 (NCI Thesaurus Property)
C0205404 (UMLS 2011AA Property)
CL282488 (NCI Metathesaurus ObjectClass)
C0221423 (NCI Metathesaurus Property)
CL.8
Code List
HAVE YOU EXPERIENCED SERIOUS ILLNESS In your family?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
HAVE YOU EXPERIENCED SERIOUS ILLNESS In caring for others?
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
CL259930 (NCI Metathesaurus ObjectClass)
C54035 (NCI Thesaurus Property)
C0205404 (UMLS 2011AA Property)
C0221423 (NCI Metathesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.9
Code List
HAVE YOU EXPERIENCED SERIOUS ILLNESS In caring for others?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
PatientAgeYearCount
Item
WHAT IS YOUR AGE IN YEARS?
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C29848 (NCI Thesaurus ValueDomain)
C0439234 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C25150 (NCI Thesaurus Property)
C0001779 (UMLS 2011AA Property)
Item
Are you
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C17357 (NCI Thesaurus ObjectClass)
C0079399 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
CL.10
Code List
Are you
CL Item
Female (FEMALE)
C46110 (NCI Thesaurus)
C0015780 (UMLS 2011AA)
CL Item
Male (MALE)
C46109 (NCI Thesaurus)
C1706180 (UMLS 2011AA)
Item
ARE YOU A current smoker
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
C0449865 (NCI Metathesaurus Property)
CL.11
Code List
ARE YOU A current smoker
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
ARE YOU An ex-smoker
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
CL.12
Code List
ARE YOU An ex-smoker
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
ARE YOU A never smoker
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C49487 (NCI Thesaurus ObjectClass)
C1298908 (UMLS 2011AA ObjectClass)
C17934 (NCI Thesaurus ObjectClass)
C0453996 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
CL.13
Code List
ARE YOU A never smoker
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
DO YOU NOW, OR DID YOU EVER, WORK IN HEALTH OR SOCIAL SERVICES?
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C17142 (NCI Thesaurus ObjectClass)
C0037441 (UMLS 2011AA ObjectClass)
CL.14
Code List
DO YOU NOW, OR DID YOU EVER, WORK IN HEALTH OR SOCIAL SERVICES?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
SocialWorkHistoryRoleSpecify
Item
IF SO, IN WHAT CAPACITY?
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C17142 (NCI Thesaurus ObjectClass)
C0037441 (UMLS 2011AA ObjectClass)
C25199 (NCI Thesaurus ValueDomain)
C0035820 (UMLS 2011AA ValueDomain)
Item
WHICH OF THE FOLLOWING BEST DESCRIBES YOUR MAIN ACTIVITY?
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25193 (NCI Thesaurus Property)
C0028811 (UMLS 2011AA Property)
CL.15
Code List
WHICH OF THE FOLLOWING BEST DESCRIBES YOUR MAIN ACTIVITY?
CL Item
Employed (In employment or self employment)
CL Item
Homemaker (Housework)
C0555052 (NCI Metathesaurus)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Retired (Retired)
CL Item
Unemployed (Seeking work)
C0425086 (NCI Metathesaurus)
CL Item
Student (Student)
PersonOccupationSpecify
Item
Other
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25193 (NCI Thesaurus Property)
C0028811 (UMLS 2011AA Property)
Item
DID YOUR EDUCATION CONTINUE AFTER THE MINIMUM SCHOOL LEAVING AGE?
text
C16529 (NCI Thesaurus ObjectClass)
C0013622 (UMLS 2011AA ObjectClass)
C0750536 (NCI Metathesaurus ObjectClass)
C25570 (NCI Thesaurus Property)
C1524031 (UMLS 2011AA Property)
CL238333 (NCI Metathesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.16
Code List
DID YOUR EDUCATION CONTINUE AFTER THE MINIMUM SCHOOL LEAVING AGE?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
DO YOU HAVE A DEGREE OR EQUIVALENT PROFESSIONAL QUALIFICATION?
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C0013658 (NCI Metathesaurus Property)
CL.17
Code List
DO YOU HAVE A DEGREE OR EQUIVALENT PROFESSIONAL QUALIFICATION?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
QualityofLifePatientAddressPostalCode
Item
IF YOU KNOW YOUR POSTCODE, WOULD YOU PLEASE WRITE IT HERE
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C1442065 (NCI Metathesaurus ObjectClass)
C25621 (NCI Thesaurus Property)
C1514254 (UMLS 2011AA Property)
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
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