ID

2043

Descripción

S0100 PREVIOUSLY UNTREATED ACUTE LYMPHOBLASTIC LEUKEMIA PRESTUDY FORM Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB40E5C-A386-418C-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AEB40E5C-A386-418C-E034-0003BA12F5E7

Palabras clave

Versiones (3)
  1. 19/9/12 19/9/12 -
  2. 2/8/17 2/8/17 - Martin Dugas
  3. 2/8/17 2/8/17 - Martin Dugas
Subido en

19 de septiembre de 2012

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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Leukemia null On-Study - S0100 PREVIOUSLY UNTREATED ACUTE LYMPHOBLASTIC LEUKEMIA PRESTUDY FORM - 2070619v3.0

Inglés

Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 formularios  
Patient And Disease Description
Descripción

Patient And Disease Description

Zubrod performance status
Descripción

PerformanceStatus

Tipo de datos

text

Height (cm:)
Descripción

PatientHeight

Tipo de datos

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25347
UMLS 2011AA Property
C0489786
Date of First Pathologic Diagnosis
Descripción

InitialDiagnosisDate

Tipo de datos

date

FAB Classification (select one:)
Descripción

Leukemia/MDSClassification

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
NCI Thesaurus ObjectClass
C3161
UMLS 2011AA ObjectClass
C0023418
NCI Thesaurus Property
C25161
UMLS 2011AA Property
C0008902
Extramedullary Disease Involvement (check all that apply)
Descripción

ExtramedullaryDisease

Tipo de datos

text

Other specify (extramedullary disease inv)
Descripción

ExtramedullaryDisease,OtherSite

Tipo de datos

text

Organ Involvement
Descripción

Organ Involvement

Palpable Splenomegaly?
Descripción

Splenomegaly,Palpation

Tipo de datos

text

Alias
NCI Thesaurus Property
C16950
UMLS 2011AA Property
C0030247
NCI Thesaurus ObjectClass
C3384
UMLS 2011AA ObjectClass
C0038002
Splenomegaly by scan or x-ray?
Descripción

Splenomegaly,Imaging

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C3384
UMLS 2011AA ObjectClass
C0038002
NCI Thesaurus Property
C19477
UMLS 2011AA Property
C1704254
Palpable Hepatomegaly?
Descripción

Hepatomegaly,Palpation

Tipo de datos

text

Alias
NCI Thesaurus Property
C16950
UMLS 2011AA Property
C0030247
NCI Thesaurus ObjectClass
C3100
UMLS 2011AA ObjectClass
C0017924
Hepatomegaly by scan or x-ray?
Descripción

Hepatomegaly,Imaging

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C3100
UMLS 2011AA ObjectClass
C0017924
NCI Thesaurus Property
C19477
UMLS 2011AA Property
C1704254
Palpable Lymphadenopathy?
Descripción

Lymphadenopathy,Palpation

Tipo de datos

text

Alias
NCI Thesaurus Property
C16950
UMLS 2011AA Property
C0030247
NCI Thesaurus ObjectClass
C3206
UMLS 2011AA ObjectClass
C0024228
Lymphadenopathy by scan or x-ray?
Descripción

Lymphadenopathy,Imaging

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C3206
UMLS 2011AA ObjectClass
C0024228
NCI Thesaurus Property
C19477
UMLS 2011AA Property
C1704254
Immunophenotype
Descripción

Immunophenotype

Tipo de datos

text

Other, specify (immunophenotype)
Descripción

Immunophenotype,Other

Tipo de datos

text

Current Laboratory Values
Descripción

Current Laboratory Values

Date of Blood Values
Descripción

Lab,Hematology,SampleCollectionDate

Tipo de datos

date

HGB (g%)
Descripción

Lab,Hematology,Hemoglobin

Tipo de datos

double

PLTS (x10 : 3)
Descripción

Lab,Hematology,Platelets

Tipo de datos

double

WBC (x10 : 3)
Descripción

Lab,Hematology,WBC

Tipo de datos

double

Peripheral Blasts (%)
Descripción

Lab,Hematology,Blasts,CellPercentage

Tipo de datos

double

Peripheral Neutrophils (%)
Descripción

Lab,Hematology,Neutrophils,CellPercentage

Tipo de datos

double

Peripheral Lymphocytes (%)
Descripción

Lab,Hematology,Lymphocytes,CellPercentage

Tipo de datos

double

Peripheral Monocytes (%)
Descripción

Lab,Hematology,Monocytes,CellPercentage

Tipo de datos

double

Date of Bone Marrow Biopsy/Aspiration
Descripción

BoneMarrowBiopsyDate

Tipo de datos

date

Marrow Cellularity (%)
Descripción

BoneMarrow,CellularityPercentage

Tipo de datos

double

Marrow Blasts (%)
Descripción

BoneMarrow,Blasts,CellPercentage

Tipo de datos

double

Marrow Lymphocytes (%)
Descripción

BoneMarrow,Lymphocytes,CellPercentage

Tipo de datos

double

Cellularity Status (select one:)
Descripción

BoneMarrow,CellularityStatus

Tipo de datos

text

Comments
Descripción

Comments

Tipo de datos

text

Ccrr Module For S0100 Previously Untreated Acute Lymphoblastic Leukemia Prestudy Form
Descripción

Ccrr Module For S0100 Previously Untreated Acute Lymphoblastic Leukemia Prestudy Form

SWOG Patient ID
Descripción

SWOGPatientID

Tipo de datos

text

SWOG Study No.
Descripción

SWOGStudyNo.

Tipo de datos

text

Registration Step
Descripción

RegistrationStep

Tipo de datos

text

Patient Initials (L, F, M)
Descripción

PatientInitials

Tipo de datos

text

Institution/Affiliate
Descripción

MainMemberInstitution/Affiliate

Tipo de datos

text

Physician
Descripción

TreatingPhysician

Tipo de datos

text

Alias
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass
C25705
UMLS 2011AA ObjectClass
C1522326
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Similar models

Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Patient And Disease Description
PerformanceStatus
Item
Zubrod performance status
text
PatientHeight
Item
Height (cm:)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25347 (NCI Thesaurus Property)
C0489786 (UMLS 2011AA Property)
InitialDiagnosisDate
Item
Date of First Pathologic Diagnosis
date
Item
FAB Classification (select one:)
text
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C3161 (NCI Thesaurus ObjectClass)
C0023418 (UMLS 2011AA ObjectClass)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
CL.1
Code List
FAB Classification (select one:)
CL Item
Disease Classified As Acute Lympoblastic Leukemia (fab L1) (L1)
CL Item
Disease Classified As Acute Lymphoblastic Leukemia (fab L2) (L2)
CL Item
Disease Is A Mixed Lineage Acute Leukemia (Mixed lineage ALL)
Item
Extramedullary Disease Involvement (check all that apply)
text
CL.2
Code List
Extramedullary Disease Involvement (check all that apply)
CL Item
Pathology Or Disease Involving The Central Nervous System Present (Central Nervous System)
CL Item
Pathology Or Disease Involving The Peripheral Nervous System Present (Peripheral Nervous System)
CL Item
Gingival Hypertrophy Present (Gingival Hypertrophy)
CL Item
Mediastinal Mass Present (Mediastinal Mass)
CL Item
Pathology Or Disease Involving The Skin Present (Skin)
CL Item
Other Specified Extramedullary Disease Present (Other, specify)
ExtramedullaryDisease,OtherSite
Item
Other specify (extramedullary disease inv)
text
Item Group
Organ Involvement
Item
Palpable Splenomegaly?
text
C16950 (NCI Thesaurus Property)
C0030247 (UMLS 2011AA Property)
C3384 (NCI Thesaurus ObjectClass)
C0038002 (UMLS 2011AA ObjectClass)
CL.3
Code List
Palpable Splenomegaly?
CL Item
Palpation Performed And Splenomegaly Present (Yes)
CL Item
Palpation Performed And Splenomegaly Absent (No)
CL Item
Palpation Of Spleen Not Performed (Not examined)
CL Item
Surgically absent (Surgically absent)
Item
Splenomegaly by scan or x-ray?
text
C3384 (NCI Thesaurus ObjectClass)
C0038002 (UMLS 2011AA ObjectClass)
C19477 (NCI Thesaurus Property)
C1704254 (UMLS 2011AA Property)
CL.4
Code List
Splenomegaly by scan or x-ray?
CL Item
Imaging Performed And Splenomegaly Present (Yes)
CL Item
Imaging Performed And Splenomegaly Absent (No)
CL Item
Imaging Of Spleen Not Performed (Not examined)
CL Item
Spleen Removed Via Prior Surgery (Surgically absent)
Item
Palpable Hepatomegaly?
text
C16950 (NCI Thesaurus Property)
C0030247 (UMLS 2011AA Property)
C3100 (NCI Thesaurus ObjectClass)
C0017924 (UMLS 2011AA ObjectClass)
CL.5
Code List
Palpable Hepatomegaly?
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Not examined (Not examined)
Item
Hepatomegaly by scan or x-ray?
text
C3100 (NCI Thesaurus ObjectClass)
C0017924 (UMLS 2011AA ObjectClass)
C19477 (NCI Thesaurus Property)
C1704254 (UMLS 2011AA Property)
CL.6
Code List
Hepatomegaly by scan or x-ray?
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Not examined (Not examined)
Item
Palpable Lymphadenopathy?
text
C16950 (NCI Thesaurus Property)
C0030247 (UMLS 2011AA Property)
C3206 (NCI Thesaurus ObjectClass)
C0024228 (UMLS 2011AA ObjectClass)
CL.7
Code List
Palpable Lymphadenopathy?
CL Item
Yes (Yes)
CL Item
No (No)
Item
Lymphadenopathy by scan or x-ray?
text
C3206 (NCI Thesaurus ObjectClass)
C0024228 (UMLS 2011AA ObjectClass)
C19477 (NCI Thesaurus Property)
C1704254 (UMLS 2011AA Property)
CL.8
Code List
Lymphadenopathy by scan or x-ray?
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Not examined (Not examined)
Item
Immunophenotype
text
CL.9
Code List
Immunophenotype
CL Item
T-cell Immunophenotype (T-cell)
CL Item
pre B-cell (pre B-cell)
CL Item
B-cell Immunophenotype (B-cell)
CL Item
Unknown (Unknown)
CL Item
Other Specified Immunophenotype (Other, specify)
CL Item
Indeterminate Immunophenotype (Indeterminate)
CL Item
Mixed Cells Immunophenotype (Mixed)
CL Item
Non-t/non-b Cell Immunophenotype (Non-T/Non-B)
Immunophenotype,Other
Item
Other, specify (immunophenotype)
text
Item Group
Current Laboratory Values
Lab,Hematology,SampleCollectionDate
Item
Date of Blood Values
date
Lab,Hematology,Hemoglobin
Item
HGB (g%)
double
Lab,Hematology,Platelets
Item
PLTS (x10 : 3)
double
Lab,Hematology,WBC
Item
WBC (x10 : 3)
double
Lab,Hematology,Blasts,CellPercentage
Item
Peripheral Blasts (%)
double
Lab,Hematology,Neutrophils,CellPercentage
Item
Peripheral Neutrophils (%)
double
Lab,Hematology,Lymphocytes,CellPercentage
Item
Peripheral Lymphocytes (%)
double
Lab,Hematology,Monocytes,CellPercentage
Item
Peripheral Monocytes (%)
double
BoneMarrowBiopsyDate
Item
Date of Bone Marrow Biopsy/Aspiration
date
BoneMarrow,CellularityPercentage
Item
Marrow Cellularity (%)
double
BoneMarrow,Blasts,CellPercentage
Item
Marrow Blasts (%)
double
BoneMarrow,Lymphocytes,CellPercentage
Item
Marrow Lymphocytes (%)
double
Item
Cellularity Status (select one:)
text
CL.10
Code List
Cellularity Status (select one:)
CL Item
Cellularity Status Of Bone Marrow Is Aplasitc (severely Hypocellular) (Aplastic)
CL Item
Cellularity Status Of Bone Marrow Is Hypocellular (Hypocellular)
CL Item
Cellularity Status Of Bone Marrow Is Normocellular (Normocellular)
CL Item
Cellularity Status Of Bone Marrow Is Hypercellular (Hypercellular)
CL Item
Cellularity Status Of Bone Marrow Is Packed (intensely Hypercellular) (Packed)
CL Item
Cellularity Status Of Bone Marrow Unknown, Procedure Resulted In No Material To Analyze (Dry tap or inaspirable)
Comments
Item
Comments
text
Item Group
Ccrr Module For S0100 Previously Untreated Acute Lymphoblastic Leukemia Prestudy Form
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
PatientInitials
Item
Patient Initials (L, F, M)
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
TreatingPhysician
Item
Physician
text
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass)
C1522326 (UMLS 2011AA ObjectClass)
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