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2043

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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

Trefwoorden

Versies (3)
  1. 19/09/12 19/09/12 -
  2. 02/08/17 02/08/17 - Martin Dugas
  3. 02/08/17 02/08/17 - Martin Dugas
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19 settembre 2012

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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

    Engels

    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 Formulieren  
    Patient And Disease Description
    Beschrijving

    Patient And Disease Description

    Zubrod performance status
    Beschrijving

    PerformanceStatus

    Datatype

    text

    Height (cm:)
    Beschrijving

    PatientHeight

    Datatype

    double

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

    InitialDiagnosisDate

    Datatype

    date

    FAB Classification (select one:)
    Beschrijving

    Leukemia/MDSClassification

    Datatype

    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)
    Beschrijving

    ExtramedullaryDisease

    Datatype

    text

    Other specify (extramedullary disease inv)
    Beschrijving

    ExtramedullaryDisease,OtherSite

    Datatype

    text

    Organ Involvement
    Beschrijving

    Organ Involvement

    Palpable Splenomegaly?
    Beschrijving

    Splenomegaly,Palpation

    Datatype

    text

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

    Splenomegaly,Imaging

    Datatype

    text

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

    Hepatomegaly,Palpation

    Datatype

    text

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

    Hepatomegaly,Imaging

    Datatype

    text

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

    Lymphadenopathy,Palpation

    Datatype

    text

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

    Lymphadenopathy,Imaging

    Datatype

    text

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

    Immunophenotype

    Datatype

    text

    Other, specify (immunophenotype)
    Beschrijving

    Immunophenotype,Other

    Datatype

    text

    Current Laboratory Values
    Beschrijving

    Current Laboratory Values

    Date of Blood Values
    Beschrijving

    Lab,Hematology,SampleCollectionDate

    Datatype

    date

    HGB (g%)
    Beschrijving

    Lab,Hematology,Hemoglobin

    Datatype

    double

    PLTS (x10 : 3)
    Beschrijving

    Lab,Hematology,Platelets

    Datatype

    double

    WBC (x10 : 3)
    Beschrijving

    Lab,Hematology,WBC

    Datatype

    double

    Peripheral Blasts (%)
    Beschrijving

    Lab,Hematology,Blasts,CellPercentage

    Datatype

    double

    Peripheral Neutrophils (%)
    Beschrijving

    Lab,Hematology,Neutrophils,CellPercentage

    Datatype

    double

    Peripheral Lymphocytes (%)
    Beschrijving

    Lab,Hematology,Lymphocytes,CellPercentage

    Datatype

    double

    Peripheral Monocytes (%)
    Beschrijving

    Lab,Hematology,Monocytes,CellPercentage

    Datatype

    double

    Date of Bone Marrow Biopsy/Aspiration
    Beschrijving

    BoneMarrowBiopsyDate

    Datatype

    date

    Marrow Cellularity (%)
    Beschrijving

    BoneMarrow,CellularityPercentage

    Datatype

    double

    Marrow Blasts (%)
    Beschrijving

    BoneMarrow,Blasts,CellPercentage

    Datatype

    double

    Marrow Lymphocytes (%)
    Beschrijving

    BoneMarrow,Lymphocytes,CellPercentage

    Datatype

    double

    Cellularity Status (select one:)
    Beschrijving

    BoneMarrow,CellularityStatus

    Datatype

    text

    Comments
    Beschrijving

    Comments

    Datatype

    text

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

    Ccrr Module For S0100 Previously Untreated Acute Lymphoblastic Leukemia Prestudy Form

    SWOG Patient ID
    Beschrijving

    SWOGPatientID

    Datatype

    text

    SWOG Study No.
    Beschrijving

    SWOGStudyNo.

    Datatype

    text

    Registration Step
    Beschrijving

    RegistrationStep

    Datatype

    text

    Patient Initials (L, F, M)
    Beschrijving

    PatientInitials

    Datatype

    text

    Institution/Affiliate
    Beschrijving

    MainMemberInstitution/Affiliate

    Datatype

    text

    Physician
    Beschrijving

    TreatingPhysician

    Datatype

    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
    Terug naar het begin van de pagina

    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 Formulieren
    Name
    Type
    Description | Question | Decode (Coded Value)
    Datatype
    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)
    Terug naar het begin van de pagina 

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